Fizzy Yoga!

by Shari

Trees in the Ocean by Brad Gibson

I recently looked into physioyoga (aka "fizzy yoga") because I was very displeased with the knee rehabilitation I was currently receiving from a local and very well-respected (in the medical community) orthopedic physical therapist. I was displeased for a number of reasons but the most glaring issue was my feeling that she was myopically looking at my problem. She focused solely on my injury, not on the many parts of  the “whole me” that predisposed me to injury, and when I brought up the various imbalances in my body, she politely listened but refocused the visit on my acute injury. I would leave feeling frustrated, but I would dutifully do my home exercise program and feel my mind disconnect from my body as I was doing them. Though we could “talk shop” about my injury, she didn’t understand or appreciate my yoga practice and couldn’t recommend anything other than “take a couple of weeks off and rest your knee.” Well in my world that recommendation wasn’t going to pay my bills!

So I decided to be more pro-active. I found a local sports medicine internist who did less invasive office procedures and had my knee drained of the edema and injected with cortisone for pain relief. I also knew that I had to find another type of physical therapist who could look at me as a whole person, not just my knee injury, and begin to assist me in the road to healing. I figured I needed to meld the traditional medical approach with the CAM model (complementary alternative medicine) to begin to address my knee injury.

I was already a member of a group called Bridge Builders to Awareness in Healthcare, a world-wide internet group of rehabilitation professionals who all practice yoga and use yoga as a therapeutic modality or therapy to treat a wide variety of chronic and acute health care conditions that have not been successfully treated in the reductionistic American health care system. Perusing this site, I found a lot of talk about “fizzy yoga” and “physioyoga.”

On the various news feeds that I have on my computer there was a lot of talk about one of the stars from “Sex and the City” who was healed from a knee injury under the care of a “fizzy yoga” therapist. Her comments about how “fizzy yoga saved my life” were sensational to say the least, and I was intrigued not only by the name but by the enthusiastic endorsement.

On the Bridge Builders site, I found an article by a Canadian physiotherapist (that is their name for the profession that I call physical therapist) named Shelly Prosko, BPT, PYT, CPI, who wrote a definition of physioyoga for a local news station. Briefly, physio-yoga therapy (PYT) is a type of rehabilitation where the client (patient) and the  medical practitioner enter into an equal partnership toward healing. It is a holistic approach, where the focus is on individual self empowerment and self healing. The physio-yoga therapist is the guide in addressing the imbalances between body, breath, and spirit of the client within the guidelines and principles of yoga.

Upon further reading, I came across some writings by one of the influential originators, Matthew Taylor, MPT, EYT, about the new 21st century health care system (see here). In brief, he draws many parallels between soft tissue structural changes (body), effects on breathing patterns (spirit) and central nervous system vigilance (mind) , emotions (mind) that all interact to create dis-health. I felt that I had finally found my health care community and wasn’t “alone” with how I approached individuals in my physical therapy work!

Okay, so now not only was I hooked, I wanted to find someone in my area to assist me on my path to healing because I knew I couldn’t do it by myself. Looking on Ginger Garner’s Professional Yoga Therapy site, I found someone who was geographically close to me. I read the testimonials that prior patients had written so I could get a sense of her treatment approaches. (This was scary because usually all of my connections are from word of mouth and this was the first time I was doing a search “blind.”)

But from the moment that I walked into this fizzy yoga therapist's office I could feel the pragmatic shift in her model of health care delivery!  She asked me numerous questions, actually LISTENED to my answers and did an incredibly through structural evaluation (physical-therapist based) and started putting associations together between my various weak links. Together on that first visit, we worked on a simple home practice that made sense to me as well as to my knee. Well, I knew that together we would figure this out! We were partners together. It was more egalitarian and not hierarchical so there wasn’t a power discrepancy. Each and every visit I have had after the first is a meeting of minds. I come with my requests for care, she discusses her observations and together we work.

Though it still isn't 100 percent, my right knee is regaining function! I can now kneel with padding for very short periods of times. I can squat, though I still can't come upright without pain. I can sit in Virasana (Hero pose) on one block and I can do Child's pose. I still can't do a lot of the activities that I was doing before the injury, and now my uninjured knee (noting how much it was compensating) has become cranky as well. But I've made a lot of progress over the last 6 months, and hopefully with time I will make even more progress.

So that's my personal testimonial! But what about you? Should you seek a fizzy yoga therapist for your physical problems? Would there be any problems or conditions that would preclude you from seeking care of a fizzy yoga therapist/physio-yoga therapist? I would answer there is only one scenario where this type of health care approach wouldn’t work. If an individual wants to be “fixed” and take no active responsibility in their rehabilitation then I don’t think this system would work for them. You can’t just receive but do have to be an active participant. The fizzy yoga therapists are licensed health care professionals and are vested with the ability to practice their profession by the state they live in. What is different—and this is a huge difference—is how they approach the issue of injury and illness.

Finally, what would I recommend in looking for a fizzy yoga/physio-yoga therapist? I would start with the links listed above and add to that another link http://www.professionalyogatherapy.org/patients/find-therapist to search for someone geographically convenient. I would not choose an individual who has only taken a couple of weekend yoga continuing education classes, and then attempts to use yoga as a modality like other types of “exercise approaches.” In this type of yoga therapy, the clinician really has "walk the walk,” and can’t be an armchair or book yogi. Your therapist's personal practice is really important, in my mind, for them to use yoga as a healing modality. The depth of personal practice can be shared and modified to individual client needs.

Now you might be wondering, since I myself am both a yoga teacher and a physical therapist, am I going to become a fizzy yoga therapist and not just a patient? I think I have been doing yoga with my physical therapy patients for years, but I just never was upfront about it. I'd say things like: "Balance training; lets do some standing poses!", "Respiratory distress? Lets work on ujaaii breathing or deep belly breathing and posture, posture posture! Where is the still point?", and "Self pacing skills? Let's learn to move with intention." The difference is that I have never identified what I do with my patients as "yoga" unless they say to me "this is like yoga!" Because I work under the constraints of Medicare, I have to play by the rules. But my therapeutic skills and my yoga skills complement each other and aren't put into diagnostic boxes when I work clinically. So for now, I would classify myself as "an undercover fizzy therapist."

Yoga for Menopause: Joint Problems

by Shari

I feel a little foolish presenting this topic because until quite recently I didn’t associate my various injuries or aches and pains as part of menopause. I didn’t really connect the dots; I just figured that I must be doing something wrong to cause myself injury. This has really come home to roost with my current knee injury that could be something I might have to address with surgical intervention! And my conversations with Nina about menopause prompted me to take a closer look at this problem that isn’t just my own personal issue.

It turns out there is actually a term for this experience: arthralgia. A diagnoses of arthralgia is given when the joints become swollen, stiff or painful during menopause. Joint pain associated with menopause is also referred to as “menopause arthritis.” It can affect hips, knees, back and extremities (how about the whole body?).  In the journal "Semin Arthritis Rheum 2009," the researchers state that genetic alteration, menopause-related estrogen deficiency and aging cause changes in joints with resultant cartilage damage. The changes in the joint are what physicians call osteoarthritis but they don't classify it beyond that. However, these researchers recommend that primary osteoarthritis be classified in the three categories listed. The literature also presents some disagreement in the usage of arthralgia and arthritis. In one source arthralgia is classified as non-inflammatory and arthritis as inflammatory. But pain is experienced in both situations.

Menopausal joint pain is often described as increased stiffness with joint swelling that increases at the end of the day. For some women, the pain may shoot down an extremity as well as feel hot within the surrounding area, which gets worse (not better) after exercise. In menopause and perimenopause the radical hormonal fluctuations are affecting the joints but researchers can’t say exactly how. They do state that changing levels of estrogen play a major role in joint pain caused by menopause. It is known that estrogen helps control joint inflammation and as estrogen levels decrease, inflammation can increase. Concurrent with the sensation of pain experienced in menopausal joint pain, range of motion may become limited (such in as the condition called "frozen shoulder").

So if it's possible that menopause is causing sporadic back or neck pain, the questions some of us may then grapple with are: "Do I investigate hormone replacement therapy?" and "Do I make dietary changes to work with my changing hormonal levels?" These are personal issues that we all grapple with, but the context of this blog is to address our menopausal symptoms with the practice of yoga! In general, for joint pain—whether menopausal or not—there are certain issues our yoga practice should address:

1. pain management
2. range of motion
3. muscle strengthening
4. acceptance

Pain Management: The key point here is how we can manage the pain (maybe not alleviate it) so we can function. What I am learning in my own pain management is that it is counterproductive to ignore it. I have to use the pain response to guide my own movements in asana. For instance, I cannot squat to the floor as I am used to doing, nor can I sit in Hero pose (Virasana) anymore (with any combination of prop usage). Do I need to sit in Hero pose? No, I don’t. Do I need to squat? Well, I do need to bend my knees to get up and down from the floor to practice yoga as well as for functional tasks. So I have learned how to do it so I don’t hurt my back and I can smoothly execute my tasks. When I do try to test things out, my knee responds with increased swelling and a nasty ache that is not fun, but I'm learning to adapt. For asana, I try to keep the injured body part within its comfort zone, and if that is not possible, I do something else in my practice. For me standing poses have always been a favorite part of my home practice, but now I find that seated forward bends are better. Certain twists are challenging for a sore knee but with a bit of creativity some of them can be nicely modified. If I was a student in a class and my teacher could not come up with a modification for me to safely do a pose, I would not do that pose and would wait until I could rejoin the class.

Shari's Go-To Pose

Yoga postures where the blood is flowing toward the heart also help with pain management, especially for swollen extremities. That means inverted poses. Try to figure out which inversions feel good to you, and then practice them daily.  For me, my go-to pose is Shoulderstand with a chair. In the past I would always choose the active Shoulderstand, but now the more passive version is more nourishing for me. When all else fails, Legs Up the Wall pose (Viparita Karani), either with straight legs on the wall or bent legs on a chair—anywhere you can make your legs higher than your heart—is lovely.

Range of Motion: As we've mentioned many times on this blog, to keep your joints healthy you need to move them through their range of motion (see Range of Motion: Yoga's Got It Covered). But too much movement into and out of pain is counterproductive. So finding the amount of motion you can do without increasing your pain response is crucial. And non-weight-bearing positions generally work better than weight-bearing poses. What does this mean? Well, lying on your back and bending your knee to its limit is non-weight bearing. Standing and putting weight on your legs to bend them is weight bearing, and when we bear weight, we compress the joint. When there is inflammation and swelling, weight-bearing compression just aggravates the inflammation and things feel worse. Time is also an important factor. Let’s say I can bend a body part for five seconds without a pain response, but if I hold it for fifteen seconds I get pain. The idea is to hold the joint in position and release it before a pain response occurs. If you have immediate pain, then that position probably should be avoided for now. In asana, using a chair for standing poses can still allow you to experience the benefits of the pose but can decrease weight bearing on the lower limbs to help you avoid increase of pain while still working with your range of motion.

Muscle Strengthening: We have to keep our bodies strong because as menopause progresses our ability to build healthy bone is affected and weight-bearing activities are what stimulates the bone to remodel. A simple technique for building strength is timing your poses (see Arthritis, Exercise and Yoga). But it may not be immediately obvious where you need strengthening. My current physical therapist (who is not a yogi) is addressing my knee injury not by strengthening my knee, but instead working on my hips. That means buttock muscles and hamstrings. Interestingly, my hips (on both sides) were a lot weaker than I thought, and I'm someone who was aerobically walking two miles a day and had a strong standing pose practice! So I am humbly learning how to do exercises that target specific muscle groups. I personally am finding this more challenging than I thought, so here is when I am trying to employ some yogic principles of breathing into the challenge and trying to engage my mind to embrace my hip abductors. If you want to work on strengthening, it might be a good idea to consult a professional, such as a physical therapist, so see which areas you should focus on.

Acceptance: We all grieve when we suffer a loss. For some women menopause is a period of grief because of the loss of the ability to bear children. I felt that acutely when my youngest child was weaning himself from breast feeding. He was 3 ½ and it was time for both of us. It was very smooth, but in my heart I did feel sadness because I knew I would never nourish my children that way again. The feeling of loss in menopause is very subtle for some of us and not so subtle for others. We are changing and there really isn’t anything we can do about it. Some of us dye our gray away because that holds our fears of aging at bay. Others have cosmetic procedures to deny the changes in our aging bodies. We all cope differently, but eventually we all do look at ourselves in the mirror and come to accept what we see. And as Nina talked in her recent post about fatigue (see Yoga for Menopause: Fatigue), sometimes we have to accept that we can’t do things at the same pace as we have always been used to. When we experience joint pain in menopause and have made our individual choices of how we want to live our menopause, yoga allows us the opportunity to explore avenues of acceptance. We will all find our way eventually.

Yoga and Menopause: An Overview

by Shari

Mushroom in Winter by Melina Meza

Nina and I were talking a while back and we realized that we hadn't yet written any posts on menopause. Well, considering that this physiological episode is a major event in every woman's life, we thought it was about time to take this on, and decided that I should start the ball rolling so to speak. Although each woman’s experience of menopause is very personal and individual, there are certain similarities that we all experience, including the end of the ability to give birth! Now this is not to imply that all woman make the decision to become pregnant and raise a child, but the physiological ability to become pregnant is age-related.

To begin our exploration of menopause, I read the book Yoga and the Wisdom of Menopause. A Guide to Physical, Emotional and Spiritual Health at Midlife and Beyond by Suza Francina. This book was published in 2003 but the information it contains is still pertinent. It provides good background information about what menopause is, and how yoga can be applied in all the stages that lead up to menopause as well as during menopause to help alleviate some of the more common issues that woman have to deal with. The usage of yoga was the unifying theme throughout the book.

Moving to specifics, I'll start by defining what menopause is and how you know you are in it. "Meno" means "month" in Greek and "pause" comes from the Greek "pausis" for stop. So menopause is the cessation of menstrual periods, an end to the monthly cycle. There are three stages:

1. The first stage is perimenopause (“pre-menopause"), when the change in hormonal functions leading up to menopause occur. Typically perimenopuase begins around age 40 (but remember this is a rough estimate) but can begin in one’s 30’s. This stage typically lasts around 5 years, but sometimes lasts for 15 years. In perimenopause women may notice changes in their menses where they are lighter and longer to heavier and more frequent. There are many hormone fluctuations and sometimes this time is called “puberty in reverse”
2. The second stage is menopause itself because the menses stop. Menopause is considered official 12 months after the last period. The average age of women whose menstrual periods have stopped is 52. Though a woman’s period has stopped, it doesn’t mean that the hormonal levels are stabilized and this period is categorized by emotional shifts, hot flashes, hot surges or flushes.
3. The final stage, which lasts the remainder of a woman’s life, is post-menopause when the woman’s body has adjusted to its hormone levels.

Most often when we think and talk about menopause, we focus on the physical discomforts, emotional roller coaster ride and weight redistribution in our bodies. But it is a time where we all are learning to adjust to our physical changes, energy changes, and mental challenges. Now Nina has written extensively in the past about emotional health and moods as well as management of depression through the usage of yoga. All of her recommendations can be applied very directly to the challenges some women experience during the stages of menopause.

My particular interest in reading this book was usage of yoga and its effect on the endocrine system and easing menopausal symptoms, especially the management of stress. The book provides illustrations of restorative poses to counter the stresses of a body adjusting to widely fluctuating hormonal levels. Supported Relaxation pose (Savasana), Supported Child's pose (Balasana), Supported Backbends with a bolster, Legs Up the Wall pose (Viparita Karani), and Supported Reclined Cobbler's pose (Supta Baddha Konasana) are highlighted repeatedly in personal vignettes as a prescription for health. (not necessarily in this order). Supported standing poses, inversions, and twists are also recommended, with the woman using a wall or a chair to prevent overly exhausting herself during asana practice. A guiding principle that is cycled back over and over again is that our practice of yoga changes as our body changes. This is not just due to physical aches and pains or the limitations in mobility, energy or strength but in how our intuitive self begins to guide us more in our asana practice.

What I liked most about this book was its celebration of the cycles of a woman’s life. Throughout the book there is joy about entering into an initiation that all women are a part of. The usage of asana is as a guiding tool to help us navigate this unknown territory. The author presents her book as a way to nourish one’s soul through the practice of asana.

Yoga and Pain Management

by Shari

Since I have been on a “pain alert” myself for the past 10 days (a very cranky knee is having trouble settling down), I thought I would discuss the difference between acute and chronic pain, and how yoga may assist in pain management.

More than 115 million people nationwide (1 in 3 Americans) suffer from some type of long-term pain, according to the Institute of Medicine. People often try to alleviate pain with conventional therapies and medications. According to the CDC, narcotic pain medication addiction and overdosing accounted for over 16,651 deaths in 2010. When conventional treatment fails, people will often turn to complementary medicine techniques, and yoga is often tried to alleviate pain symptoms.

I thought I would first define the difference between acute and chronic pain. An acute injury will typically resolve within three months of the body’s normal healing process. Chronic or persistent pain is pain that lasts more than this time frame. Acute pain is associated with tissue damage. Pain (nerve) receptors are activated with an acute injury because the body is trying to protect the damaged area - this minimizes usage so normal healing can occur.

But with chronic pain, the brain’s perception of the cause of the pain changes. The inhibitory mechanisms of the central nervous system become faulty, and we may avoid physical activity because we have learned “If I do this, it will hurt.” We may be afraid that, because we are in pain, activity will further damage or injure the area. But generally the tissue damage is healed after three months, and avoidance of physical activity is therefore no longer beneficial in the healing process.

However, the brain may now remember stress and pain in an exaggerated way, as if it were in a continuous sympathetic feed back loop of fight or flight. So some of us can become hyper vigilant about everything that causes pain. But one of the beauties of yoga practice is how helpful it can be for people both in acute and chronic pain!

Physical asana has properties of both squeezing and soaking areas of the body. Compressive forces, with and without weight bearing, and long restorative poses move fluid, assisting the body to decrease edema in a joint after an acute injury. Decreasing the edema reduces the pressure on nerves and muscles, resulting in a reduction of pain symptoms. (However, it is key to understand how much can you can move your cranky joint and when you need to stop, so see When to Stop Practicing Yoga for information.) Along with the practice of physical asana, long relaxation poses and Savasana can help because of their restorative qualities and the way they quiet the sympathetic nervous system while stimulating the parasympathetic system (the relaxation response). And at this time, modifying the asanas that you regularly do is important. This way, you can still get the benefit of the asana with modifications, and then as the injury heals you can slowly bring the full asanas back into your regime.

For chronic pain the “prescription” is a bit different. Chronic pain is a global body phenomenon. When your body is in chronic pain you walk differently and you may even sit differently. Your attention is often directed to the painful region because keeping it still may make it worse and positional change needs to be frequent. The individual may be chronically exhausted because the ability to sleep well has been affected. There may be difficulty in completing tasks in a timely manner so things “start to slide” and don’t get done. Because energy is limited, the individual may rush through tasks to get things done and then be in more pain because they hurried. It is a terrible wheel to be on and difficult to get off onto solid ground!

In my own practice and teaching of yoga, I try to share with my students how yoga helps to focus the mind, quiet the breath and improve the mental focus. Yoga meets us where we are NOW. Yoga is nonjudgmental and everyone can do yoga. Yoga teaches us self-awareness. Yoga gives hope where there may be no hope.

Simple grounded breathing while you sit on a chair or lie in bed in your position of comfort is a great way to start. Set a timer and do simple breathing for three to five minutes. Notice how this may affect your mind and sense of self. Progressing to GENTLE range of motion of all body parts within your ability and not pushing yourself is beneficial. You can even do your range of motion activities in your position of comfort. Notice your pain levels (0-10) at start of practice and then again when you are done. If your pain levels stay the same, you are teaching your body NOT to be afraid of movement. Once your confidence has improved, then you might be ready to join a local class. Look for instructors who will be sympathetic to your pain but not overly solicitous. Make sure the teacher understands that you will stop when you need to, not necessarily when the teacher tells the class to release the position. Try to set aside five minutes a day to practice your own breathing awareness and your own Savasana. It becomes your sacred time to care for yourself.

Remember, the results may be slow in coming but persistence and gentleness are the keys to relieving and managing both acute and chronic pain.

Note: For my achy, swollen and hot knee, I am trying to work with my available range of motion, not moving too much into pain but inching into the pain and then backing up and repeating multiple times trying to make the available movement  smoother. Also, stretching related areas like my hip flexors, hamstring muscles, gastroc/soleus is really helpful for pain relief of my knee. In the standing poses, I’m working with gentle isometric contractions but not going into my full knee flexion (bending)—pumping a lot. I’m doing a lot of passive inversions like Viparita Karani (Legs Up the Wall pose) and Chair Shoulderstand, with pumping from my ankles. And, finally, modifying poses, for example, for Virasana (Hero pose), which I was previously able to do without any props, I now use two blocks stacked up high because I have just about 100 degrees of flexion (ability to bend the knee). And, lastly, cautious, aware walking. Patience is the crux though I am not a very patient individual.

When to Stop Practicing Yoga

by Shari

Swan at Rest by Brad Gibson

Sometimes we do things that we think are healthy or beneficial for us, but which are actually not. Even practice of yoga, whether at home or in a class, can occasionally be problematic. Have you ever gone to a class feeling a “bit off” and then walked away from the class feeling drained or in actual pain? Or, have you ever gone to a class feeling a “bit creaky” but hope that the “kinks” will work themselves out, but instead of feeling in less pain, you are in more pain after class? I don’t think this is a situation that only I have experienced in my over 30 years of practice! And I have begun to think of this topic as a means of exploring self-empowerment and non-judgment.

So, why do we continue to participate when we know we should stop? All of my fellow bloggers have addressed this issue in slightly different ways, whether it is in our approach to eating, sleeping, or basic life stressors.

I think we can explore this idea on a psychological /emotional level or on a gross physical level. I will start this discussion with the gross physical level of the body. First off, the practice of asana is not just a physical body moving through space following the commands of our central nervous system. Each time we move into a yoga pose there can be a flurry of self-judgments and criticisms—”Oh no, not this pose again, I can’t ever do this, I hate this…”—the internal psychological dialogue can be unending. It takes a lot of mental discipline to quiet the mind to be fully in the asana. But then the actual physical body can start its own chorus of complaints—“This is making my knee hurt, or my back or my shoulder.” The mind can and does ignore a lot of this noise, “strong arming” the body into submission. But that cranky joint knows when to strike back and it often does. So, when should we listen to the body over the noise of the mind?

I often tell my students that it is extremely important to understand our own physical as well as mental limitations and to respect them. Pushing beyond one’s actual abilities does lead to injuries (see Baxter's post Getting Clearer on Yoga and Risk of Injury). So when and how do we improve our abilities without causing injury or damage? We have to know when to stop!

With that in mind, here is a list of physical warning signs that would be important to acknowledge:

1. Pain progression in both intensity and location. A back pain that is located centrally in your spine that starts to spread outward or downward is a warning sign to stop that activity. Another warning sign is when the area of pain totally changes location from back (spine) to arm or leg.
2. Pain intensity. Pain is usually quantified on a 0-10 point scale where 0= no pain and 10 is excruciating intense pain. Any pain that moves from negligible, like a 3, to a 6-7, is not something you want to encourage. 
3. Loss of sensation in a limb, an increase of numbness, a tingling, or burning that doesn’t stop once the position is changed.
4. Increase in a sense of “unease.” You don’t know why this activity is making your nervous, unsettled or agitated, but it would be wise to stop the activity and ask your teacher afterwards.
5. Any sensation of dizziness, nausea, double vision. These are not symptoms that are a healthy benefit from asana.
6. Any signs or symptoms of heart racing or feeling that your heart beat feels irregular.
7. Physical exhaustion. Instead of feeling better as the class progresses, you start to feel more and more exhausted.
8. Mental exhaustion.

If any of these events occur during a class it would be wise to stop and sit leaning against a wall. Sometimes closing your eyes or going to get a drink of water will be helpful. Other times just stopping and lying down in Savasana will work. Finally, there may be times actually leaving the class is necessary. If this occurs, quietly get up and leave the room. Your teacher may or may not come to talk with you. If he or she does approach you, briefly let the teacher know what is going on with you. If you are concerned about discussing medical issues in front of the class, only discuss what you feel comfortable with. Then, especially if this is a regular class that you attend, consider contacting the teacher afterward to give him or her the complete information. Having complete information about your condition will help your teacher do a better job of making your next experience in class a good one.

For information about what you might want to tell your teacher before a class, see What Your Yoga Teacher Really Wants to Know.

Range of Motion: Yoga's Got It Covered!

by Nina and Shari

Moving the Shoulder Joints

In the spirit of trying to focus on the benefits of yoga practice (see We Didn't Mean to Scare You) and not just potential problems, I’ve asked Shari Ser to work with me on a series of posts about the special benefits of yoga asana practice. One of the special benefits of yoga asana practice that I’ve really come to appreciate in recent years is how helpful it is for maintaining and/or improving range of motion in our joints. Yeah, I know that sounds kinda nerdy—and “range of motion” is definitely a technical anatomical term. But I really feel it is worth understanding this concept and why it is one of the ways in which yoga is such a wonderful and versatile form of exercise. I decided to start by asking Shari to go over the basics.

Nina: What is range of motion?

Shari: Our bodies move through space because of the unique construction of how our bones fit together to form joints. Muscles are what make these joints move through space; physical motion is caused by muscle contractions. All joints in the human body have an optimum amount of motion, but specific joints in the body, such as hip joints or shoulder joints, don’t move the same way due to unique architectural constructs. When we describe joint motion we are talking about how much movement occurs at a specific joint, and this motion is called the RANGE OF MOTION (ROM).

All joints of the human body have a prescribed degree of movement. Range of motion is described very precisely by medical professionals, and they have determined specifically how much motion a shoulder joint has, a knee joint has, a thumb joint has, and. These measurements are considered the "normal" range of motion of the joint.

When a joint moves more than the prescribed degree of normal movement, that joint is called “hypermobile.” (Have any of you had a yoga teacher tell you that one or more of your joints is hypermobile?) When a joint moves less than the prescribed degree of normal movement, that joint is called “hypomobile.” There is also a basic principle regarding joint movements: the more flexibility, the less stability; the more stability, the less flexibility.

For those who have an overly mobile joint, we can practice yoga to gain stability and strength to control our excessive flexibility and ROM.

For those who have limitations in ROM, which can be caused by muscle weakness, muscle tightness, arthritic boney changes where some barrier is stopping movement (like bone spurs), inflammation and swelling from acute injuries, yoga can be used as a therapeutic modality for ROM gain. 

Nina: Yes, I have often heard from my teachers, that students who are overly flexible need to build strength and stability and students who are tight need to work on increasing flexibility. And since we have both stretching and strengthening in yoga, it’s perfect for both groups. But let’s talk now about why range of motion is important for healthy aging.

Shari: A yoga teacher once said to me, “I do yoga so I can do the other things in my life that are important to me.” I don’t think I understood her comment way back then, but now in my 50’s I definitely do! To maintain optimum ROM throughout all my joints allows me to continue to be independent and take care of my business. Several posts back, Baxter talked about independence in seniors when he visited nursing homes or assisted living facilities (see Transferring and Yoga: Wisdom from Jane Fonda). It is the little things that we take for granted, like bending down to pick up a paper clip or tying our shoes. If I didn't have full mobility in my shoulders, hips, back, knees, or the dexterity to do a fine task like tying my shoes, I would either have to change my style of footwear or ask for assistance! The other objective in keeping up your joint ROM is "use it or lose it." Putting your body into positions (asana) that it might not do daily allows for ROM maintenance, keeping arthritis at bay, keeping muscles strong and healthy, and encouraging full body circulation by the squeezing and soaking that asana encourages.

Nina: Why is yoga better than other forms of exercise in maintaining ROM in joints?

Shari: If you have limited time to exercise and are looking for the best type of exercise for ROM, yoga is often recommended. But why wouldn't another type of full body exercise like walking or swimming be just as good? In our yoga practice we rarely do the same routine daily. For a well rounded yoga practice—whether we are in a class or practicing on our own—we vary what we do. We emphasize different motions to cause our joints to move in many different ways and directions. Some days we might choose to do standing poses and focus our practice on hip motions or our spinal motions like twists or forward bends, or backbending. Other days we might emphasize our shoulders and spines in backbends or inversions. Our choices are practically limitless and often depend only on our skill set, time and focus. In other types of exercise like walking, we might vary our walks by emphasizing a hilly walk or a walk with a lot of stairs. We can vary our speed of walking and our stride length. We can certainly walk to increase our heart rate, and we can definitely bring our hearts into a training zone. But walking does not improve our ROM and quite often can actually make us less flexible. Swimming, another full body exercise is also quite popular, and while it definitely can improve ROM through varied strokes and resistance, it does not fully involve all our joint ROM like yoga.

In addition, the beauty of yoga for ROM maintenance and improvement is the adaptability of asana to meet us where we are. With a skilled teacher almost every single yoga asana taught to a beginner can be modified to take into consideration ROM loss. With the usage of different props and static holding of an asana we can improve flexibility and motion significantly over time. The only downside is that yoga changes are slow and take patience.

Nina: That’s a great point about how all the poses can be practiced in one form or another, even by beginners, because that means that all the benefits for joint range of motion are available to every practitioner. So what kind of yoga practice would you recommend for someone who is concerned with maintaining and/or increasing range of motion in their joints?

Shari: Your practice should include a wide array of poses that are kept lively, with focusing on a different concept each time you practice. No daily practice should always be the same because we will not improve our abilities and an unvarying practice can lead to overuse injuries.

To maintain or increase ROM in a particular joint, such as your hip or shoulder joints, we need to challenge the joint we are focusing on. Taking the joint into a stretch and statically holding the stretch for up to 30 seconds will cause scar tissue to begin to stretch. The key point here is to make sure that the stretch feels broad and there is NO RIPPING sensation. This is when props might be suggested to make a pose more accessible, and then once the pose is understood, slowly removing the prop support so you have to "work a bit harder." There are plenty of techniques for stretching which all of us have touched on in the past so you might want to review these posts again (see How to Stretch among others). Also when there are ROM limitations on one side only, please only go into the range of movement for the stiff joint and limit the more flexible side. This will help you keep symmetrical in your practice.

Nina: Thanks, Shari! For me, at this point in my life, I really value how yoga includes such a rich variety of poses and ways of practicing that allow us to take our joints through a variety of motions. For example, the various standing poses, many with a feet-wide-apart stance, take your hips and shoulders through forward bending, twisting, backbending, and so on. I can’t do them all every day, so I try to balance my week by doing different standing poses on each of the days so by the end of the week, I’ve gotten through most if not all of them. I also do regular hip stretches to maintain ROM in my arthritic right hip—and so far, that’s been working well! 

And, dear readers, I hope this discussion helps deepen your appreciation of yoga asana practice. And if your practice isn't already filled with variety, I hope you'll be encouraged to start to mix it up!

What is Osteopenia? And How Can Yoga Help?

by Shari

Last Friday Baxter answered a reader’s question about osteopenia (see Friday Q&A: Yoga and Osteopenia), regarding whether or not yoga practice on its own is sufficient to maintain and/or increase bone strength. By chance, we recently received a request for an article addressing “dangerous” poses for osteopenia. Since most of you probably don’t know much about osteopenia—and its relationship to osteoporosis— we decided it was about time to provide some background information about the condition. I promise I’ll get around to answering the reader’s question eventually! Look for it this coming Friday.

Let’s start by discussing osteoporosis, which is a disease in which bones become fragile and are more likely to break or fracture due to loss of density (not bone strength). It is not painful and many people (both men and women) don’t even know they have it or are at risk for developing it until they take a DEXA scan. The DEXA scan (dual energy X-ray absorptiometry scan) measures bone mineral mass, because medical researchers have discovered that there is a correlation between bone breaking and bone density loss. But the DEXA scan can also cause lot of confusion because it doesn’t take into consideration the different way bones are constructed. Some bones are short and fat, and some are long and thin, and differently shaped bones can have different density readings. Bone mass is affected by both how densely a bone is constructed and by its corresponding physical dimensions.

Femur Bone

The World Health Organization has defined the statistical measurements of bone density through a system of comparing your numbers to women of the same age, height and weight, and then comparing them to the average measurements of women age 25-30 that are at the peak of bone strength. Three areas are measured in the DEXA scan: lumbar spine, total hip, and surgical neck of the femur (thigh bone). Two scores are given:

• T score, which is the measurement of bone mineral density and how your score compares to healthy 25-30 year old women.
• Z score, which is the comparison to women your age, height and weight.

Osteopenia is defined as a T score of 1 to 2.5 standard deviations below the mean (negative numbers), and means that you are at risk for developing osteoporosis. Osteoporosis is defined as a T score of 2.5 standard deviations below the mean (negative numbers). The higher the T score (or the more negative the numbers), the higher the fracture risk.

The correlation between a low bone mineral-density reading in a DEXA scan and a higher fracture risk is stronger than the relationship between high blood pressure and a stroke. But even though the test detects 9 out of 10 people with osteoporosis, the test is not perfect and it wrongly diagnoses healthy bones between 5-7% of the time. Also, readings will differ in different test sites, so for consistency the same test facility needs to be used for repeated scans.

So how does yoga fit into this picture? Bone has two main components: outer bone and inner bone. Bone is a living matrix of living cells and canals that are interrelated. Outer bone, which surrounds inner bone, is called the cortex and it forms a hard outer ring and is a large part of bone strength. Its construction is fairly uniform in individuals. Inner bone is spongy and is called cancellus or trabecular bone. It varies greatly in individuals. For us to improve our bone health we want to not only build outer bone but also inner bone.

Wolff’s law describes bone strength as follows:

1. The architectural strength of a bone develops along the lines of force that the bone is subjected to.
2. If a bone is loaded, the bone will remodel itself over time to become stronger and resist that sort of loading.

In conjunction with Wolff’s law there are some other important forces that act on the bones to improve bone strength and density:

1. Gravity increases bone loading. 
2. Muscle contraction increases bone loading. Dynamic tension occurring between muscle agonist and antagonist affects the bones by applying opposite pressures, and the forces are doubled on the bone.
3. Muscle activity stimulates bones to strengthen themselves more vigorously than weight bearing alone.

In our yoga asana practice, we not only take weight-bearing positions, such as standing poses, but all the active poses involve muscle contraction in some form. And the great variety of poses and movements means that all your bones are involved! In addition, Dr. Loren Fishman cites from his extensive research on osteoporosis that bone stimulation (growth) occurs after 12 seconds of static (isometric) hold but not more after 72 seconds of hold. 20-30 second holds are recommended for bone stimulation. And 20-30 second holds are quite typical for many of the poses we practice.

Now you can see why yoga is recommended for people with osteopenia as a way to prevent the development of osteoporosis and is also considered beneficial for people who already have osteoporosis. And for those of us who don’t have either condition, yoga is a very versatile and adaptable way for maintaining our bone strength. However, because osteopenia means more fragile bones, certain yoga poses are considered risky for people with the condition. Tune in Friday for my answer to the reader’s question about those poses.

Ruminations on Health: What We Can and Cannot Control

by Shari

Branches by Brad Gibson

I grew up in an eastern European Jewish household where dinnertime conversation often centered around health. Family gatherings were punctuated by relatives recounting details of various  ailments and how many doctors they were seeing. They were often pretty graphic in their descriptions during these mealtime conversations. My family’s preoccupation with their bodily functions struck me as odd as a child, and I didn’t understand how people could complain about their health but not really do anything about it. I made a conscious decision at that time to be proactive with my own health, and my lifestyle decisions and pursuits since then have reflected this.

Now I'm at the age where I am regularly receiving AARP notifications, and I'm starting to reflect on how I may be more like my parents and family than I may like to think. How many of you regularly talk with your friends about your health concerns or routine tests that a physician may be prescribing or recommending? We talk about these issues partly to become informed about procedures, but also to commiserate and offer support and empathy when complications occur. We often compare notes on which care providers have been helpful to us. There have even been times where I have looked up providers on YELP to see what their ratings were. During the AIDS epidemic in the 1980’s, my husband and I lost many friends, so we learned that illness isn’t just for “old people.” And how many of us have lost loved ones and acquaintances to cancer or other chronic diseases?

In the yoga community there are many passionate individuals who believe whole-heartedly in a way of health that I feel is fairly rigid. My own personal pet peeve is the often unspoken allegation within alternative healthcare communities of “healthy living” that if you lived a more “pure and holistic life,” this illness or health problem wouldn’t be happening to you. Too many women I have known with breast cancer have felt the twinge of anxiety that they were the cause of their own cancers. But how much do we owe to our own genetic predispositions rather than to emotional and environmental stresses?

My mother, for example, died of multi-infarct dementia, which caused severe dementia in her last years. She was a cholesterol producer, and no amount of dietary restrictions or faithfully taken statins could keep her cholesterol levels within “therapeutic ranges.” And lo and behold, right after I turned 57 and went for my annual physical and blood work, my doctor contacted me to tell me my “bad cholesterol levels were high.” With further blood work, using more sensitive lipid panels and getting a more complete picture, my numbers came back better. But I was still demonstrating risk factors, so my doctor counseled me on good nutrition (which I already practice), exercise (which I already do), and stress reduction (which I already do). She then commented to me, “Well I suppose this is where your genetic history is coming into play and we just have to watch it.” Oh dear, I thought, now what?

In Melitta’s recent post Aging, Diabetes and Yoga I was struck by her self education regarding Type 1 diabetes, and how she had to play an active role in her healthcare management, even educating her physician on the nature of her disease to get a proper diagnosis. Her story emphasized the need to be involved in your healthcare decisions and not be passive in accepting what “experts” tell you. But it was also inspiring to me because here was someone who was both realistic about her condition (yoga cannot cure Type 1 diabetes) but who at the same time found yoga invaluable for helping her live with (and work with) a chronic condition.

It got me thinking about my own situation. I considered becoming more restrictive with my fat intake, but then concluded it would lead to more stress in the long run. I came to the conclusion that I had to accept my genetic heritage. No, I wouldn’t become like my extended family and bemoan the state of my health, discussing it whenever the opportunity arose while taking no responsibility for my actions. Nor would I become strident in regimenting my life with countless restrictions and intentions. Instead I decided to mindfully continue to engage in activities that made me feel good while maintaining an awareness and consciousness of what and when I ate. As in my yoga practice, I will aim for balance and intention. My genetics are a big factor in my health, but my lifestyle and personal practice of yoga seem to be potent tools that I can use in accepting my genetic hand of cards!

Staying Safe with Degenerative Disc Disease

by Shari

I thought I would follow up on Baxter’s excellent post about preventing spinal degenerative disc disease Degenerative Disc Disease and Yoga by discussing how you might practice yoga safely after receiving this diagnosis.

To begin, it is important to understand how to influence the health of your spinal discs in your asana practice. The spinal discs acquire their nourishment from movement. In asana we move the spine throughout a range of motion that includes flexion (forward bending), extension (backward bending), rotation (twists), and side bending. Almost all asanas combine these movements. Rotation and side bending always occur together, for example, in Triangle pose (Trikonasana). And flexion poses (forward bends) will often be counterbalanced with extension poses (backbends) and vice versa. A well-rounded asana practice will include all these motions in almost every single pose, even Savasana (Relaxation pose), depending on how you position your legs.

If you have received a diagnosis of degenerative disc disease, this indicates that your spinal discs have become brittle and thin. Because of the inherent changes in their structure, the spinal discs are more prone to injury. The vertebral body is supposed to be the main weight-bearing surface for the spine while the intervertebral disc distributes the weight and acts as a shock absorber for stresses that occur from gravitational loading. But when the disc is compromised, more weight-bearing through the vertebra will be distributed onto other structures. Some of this weight may be transferred onto your facet joints, which are not weight-bearing structures but mobility structures of your vertebral column. And with this increased weight-bearing, your body may then respond by the formation of “more bone” for protection of these structures, which can be come painful bone spurs.

The Spine with Its
Three Curves

So what is a poor yogi to do? Start by returning to your Tadasana (Mountain pose). Because postural habits are one of the most important factors in developing degenerative spinal changes in the discs, learning to stand well both on and off the mat is critical in maintaining spinal health. When you think about it, even though you practice daily for 30 minutes, eat well, get enough sleep, have a good meditation practice, and are happy and healthy, if your posture is compromised, the result as the years go by is spinal compression. Learning to incorporate Tadasana into your everyday activities of driving, sitting, bending, and so on, will go a very long way in lessening the impact of spinal compressive forces. This means keeping a “Tadasana spine” (with all three spinal curves) as you move from your hips, and learning how to bend and reach and twist without causing excessive pressure through your discs and vertebrae.

In addition to maintaining your Tadasana spine, I would also recommend that you use props when either doing your own home practice or attending class. Using a strap, chair, block or wall can be helpful in teaching you what your own body can do without pain. To keep your body safe and healthy, you should ensure that your asana never hurts.

Those of you who practice Iyengar-style hatha yoga will know what I mean when I say “props” but for those of you who practice different styles of yoga this may be a foreign concept. In that case, I recommend that when you practice you at least pay very close attention to how you are moving. Where do you initiate movement from when you go into or out of a pose? Where do you start when you come out of a pose? How do you use your hips? And your legs? Where is the weight and force coming from? Do you quickly move through a motion because it hurts but once past that “bad spot” you are okay? What happens if you don’t go so low or so deep?

In addition, working on core strengthening, using your legs effectively, breathing correctly, and maintaining (or developing) adequate flexibility will all help in keeping your spine safe.

Finally, I suggest examining how you set yourself up in Savasana. Both Nina and Baxter have talked before about different ways to position yourself in Savasana (see Savasana Variations). The version with legs on a chair (be sure the chair is the proper height for your body proportions) puts your spine into a more “neutral position” than when your legs are straight out on the floor. But this isn’t necessarily comfortable for every one. When we lie on our backs, some of us like to feel the small of the back making more contact with the floor while others of us like a bit more arch. That is the thing with all degenerative conditions: one size doesn’t fit all. So a bit of experimentation is important. It’s also a good idea to consider your sleeping positions and the support of your bed. If you aren’t well-rested and comfortable in your bed, then no amount of yoga is going to make you feel better. So take the awareness you bring to Savasana—and all your yoga poses—into your bed with you to set yourself up for a comfortable and healthy sleep.

Yoga and Shoulder Joint Replacements

by Shari

Nina and Baxter asked me to finish up the total joint replacement series with a discussion about shoulder joint replacements. Like the other joint replacements previously discussed, people will consider shoulder joint replacement when all other conservative approaches have failed. The difference in shoulder joint replacement compared to hip or knee replacements is that this procedure is far less common. So if you are thinking about a shoulder replacement, it is considered a good idea to find a physician who has already done a significant number of these surgeries (one place to look is the American Shoulder and Elbow Surgeon’s Society).

Now let’s review why you might consider this treatment. Pain is often the most significant problem that an individual is suffering from. Other symptoms might include stiffness, loss of functional motion, inability to sleep on that shoulder, decreased range of motion and symptoms that are worsening with conservative treatment approaches (whether western or alternative methodologies).

Healthy Shoulder Joint

Regardless, your first step should be thorough diagnostic and physical evaluation from a qualified surgeon that includes X-rays and whatever other tests the physician orders. There has to be a differential diagnosis that separates out the cause of the pain. Rotator cuff tears or avulsions, frozen shoulder, cervical and thoracic spinal pain, shoulder bursitis and other forms of soft tissue inflammation, avascular necrosis (in which the blood supply to the joint is affected), and infections will all cause shoulder pain that can be unrelenting. Metastatic disease or other tumors can also be the cause of shoulder pain so the differential examination is critical in trying to pinpoint the problem. So only once it has been determined that your shoulder pain is due to arthritis (where the cartilage covering the joint surfaces is affected) should you explore your options for shoulder replacement. After you have determined that you’re a good candidate for the surgical joint replacement, you will probably wonder how is surgery this going to affect your yoga practice, including how longer after the surgery will you be able to do yoga again and, when you do resume practice, which poses should you avoid and for how long?

Shoulder With Joint Replacement

According to my research as well as my personal experience as a physical therapist, yoga practitioner and yoga teacher, this procedure has significant post-operative protocols. This means that there is a very specific healing algorithm that your surgeon will adhere to. It does not help if you are a “fast healer” because if you push too much and too fast, for this surgery in particular, you will be setting yourself up for significant problems in the future. This surgery is very complicated because the subscapularis is detached to expose the glenohumeral joint and then reattached after surgery. The rotator cuff may also need to be repaired because often in severe shoulder arthritis, the soft tissue ligaments and muscles are severely affected and may also need repair due to compromised biomechanics and impingement in the shoulder joint.

The literature I reviewed states conservatively a three-month recovery but more common is six to twelve months post-operative recovery with very strict dos and don’ts. And unfortunately I cannot go into what you can and can’t do here on this blog because that is totally dependent on your surgeon and which type of procedure he or she deems is appropriate for you (there are four different types of shoulder replacements).

But from a yogic perspective, here is what I can recommend. Start by being in the best possible health you can be before surgery. Understand that you will have a lot of work to do in your post-operative recovery, but believe 100% in your ability to recover and in your surgeon.

Have stress management techniques that you do regularly as part of your healing repertoire. Pain medication is not something to be shunned but used responsibly and respectfully as part of your healing process. But, because pain is a very subjective experience, yoga and stress management techniques, though not substitutions for pain medication, can be an adjunct in allowing you to “relax into the pain.” Deep breathing in particular does a world of good for your body post operatively and into your healing process. It allows your lungs to be used to prevent post-operative complications, and is also calming and a good focus for your mind when you might be counting the minutes until you can take your next pain medication dosage. Simple deep breathing also assists in decreasing muscle tension from unconscious holding and splinting because you are in pain. You may also want to work with lengthening your exhalation to assist in stimulating your parasympathetic system (triggering your relaxation response). Other stress management techniques you could explore include: meditation, Savasana (Relaxation pose), and Yoga Nidra.

Be familiar with restorative poses, such as Reclined Cobbler’s pose (Supta Baddha Konasana), Legs Up the Wall pose (Viparita Karani), and Supported Relaxation pose (Savasana) that you can do while adhering to the post-operative protocol. Shoulder positioning and propping is very important for your post-operative pain management, and your physical therapist or surgeon (or their support staff) should be able to assist you in ways to position for improved comfort. Once you understand how to position your arm in these poses (for example, using support under your arms and shoulders or having your arms in a neutral position) then you should be able to figure out how to set yourself up for restorative poses without putting your shoulder into a compromised position. Remember, how you go into and out of poses, including restorative poses is important. You may find that your bed is a perfect place to practice restorative poses because it is easier for you to position yourself.

Once you are allowed to start exercises with your physical therapist, be very clear in asking when you can do which poses, bringing pictures to demonstrate. Taking your arms out to your sides in standing poses may or may not be possible because just the weight of your arm being statically held may be contraindicated. Then, before you return to your yoga class, please contact your yoga teacher and explain your limitations and restrictions. It is your responsibility to educate your yoga teacher on your particular needs and then he or she can help you keep your practice safe within the guidelines you understand from your physician.

Finally, please be gentle with yourself and don’t overuse your arm even just a little bit. When you are allowed to stop wearing your sling, you might find that you can practice with your sling on more successfully then with your arm out of it. Stay away from weight-bearing poses like Downward-Facing Dog pose until you have medical clearance (even Half Dog pose at the Wall). Night-time positioning and pain management are often the most challenging. Make sure you understand your pain medication recommendations and do what ever your surgeon tells you. After all, you only want to do this surgery once. So be patient and creative. And good luck!

Keeping Your Sacrum and SI Joints Happy and Healthy

by Shari

Keeping His Sacrum Happy and Healthy

Now that I’ve described how the sacrum moves (see Yoga and the Sacrum), let’s look at how the sacrum and sacroiliac joints work in some of the typical yoga poses we encounter in a class, and how to keep your SI joint healthy and happy while you do them. Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

Note that if you think you might be having sacroiliac join problems but are not sure, I would recommend that you should not try to diagnose yourself. Instead, please try to consult a health care professional for a diagnosis. And although this injury is more common in women, it definitely occurs in men as well, so you guys should also get yourself checked out. Finally, for any of you pregnant yoga practitioners or teachers who teach pregnant women, all of these suggestions that follow are beneficial for pregnant women.

Now let’s get started at the beginning of a typical class. Warm ups are often asymmetrical because we work first with one leg and then the other. A typical warm-up series might include hip openers, reclined leg stretches (Supta Padangusthasana), Figure Four pose, and so on. Any type of hip opener that is asymmetrical will put different stresses on your SI joints. So for our Figure Four pose, when we stretch the piriformis on the right, the sacrum will be turned to the side that is being stretched, the right side. And conversely the sacrum will be turned to the left when we stretch the left piriformis. That’s all well and good, except if you have a piriformis that is already in spasm. Stretching it more only inflames that poor little muscle, so avoid this asymmetrical position if it hurts (or if starts to hurt while you’re in the pose, come out).

Leg stretches are also poses you may need to approach with care. If you are really tight, when you stretch your hamstrings, the hamstrings pull on your ischial tuberosities ( the sitting bones of the ilia), which flattens your lumbar spine and pulls your sacrum into a flexed position. This may cause you pain because as your sacrum is pulled down into the ilia, the two sides may not be moving equally (one side will be moving more than the other side).

When you take your leg out to the side and are stretching your adductors, try not to roll onto the SI joint of the raised leg and have the opposite side of the pelvis roll forward. Learn to move from your hip joint and limit the stress through your sacrum. If one side is tighter than the other, this may also create an asymmetry in the sacrum that will cause pain. In this case, less stretch is better (use a wall to stop the stretch on the raised leg, or use a block, chair, or bolster to limit the stretch).

For standing poses, if you are having SI problems, focus on symmetrical poses and using props. Also, be kind to yourself—think I am going to do 50% not 125%. Standing poses which are done with wide legs and an asymmetrical pelvis position may strain the ligaments holding the sacrum in place, which can then cause subsequent pain. Try firmly contracting the back leg to give some stability to the sides of the sacrum. Although Wide Legged Standing Forward Bend (Prasarita Padottanasana) is a symmetrical pose, how deep you go into the pose and what position your spine is in will all contribute different problems to the sacrum. So, when in doubt, try to keep your spinal curves in neutral and use a chair to take the torso’s weight and do less stretch than more.

In seated poses, spinal position is paramount. You want to keep your spinal curves in neutral and have enough height under your ischial tuberosities (sitting bones) to encourage your ilium to rotate over the femoral heads (hip joints). And never use your arms to pull yourself into pose, but instead rely on your abdominal muscles and spinal stabilizers. This applies to all practitioners, as both a preventative approach for those of you with no current problems as well as a therapeutic approach for those of your with SI problems. As Baxter mentioned, you want your sacrum to move with the ilia, not to be “held back.” If you are currently having symptoms, I would avoid revolved seated poses for quite a while until the symptoms are gone and you understand your vulnerabilities.

Backbends will either feel great or terrible, depending on your issues. Backbends and forward bends position the sacrum into very different positions. In forward bends the sacrum is less stable. In backbends the sacrum is more stable. But stability doesn’t mean it is going to feel good if the inherent alignment of the bones is not congruent.

If backbends feel good, pay attention to symmetry in how you go into and out of a pose. And be careful not to tuck the bottom of your spine—you lumbar spine needs to be in lordosis (curved) when you do backbends, which then puts the sacrum into a more optimum position. And less is better than more as you are healing.

However, if backbends feel terrible, don’t do them. Rather than putting a block under your sacrum in an easy Bridge pose, try an active Bridge pose and slowly evaluate how you feel afterwards. Less lifting is also crucial.

I hope this advice is helps you keep your sacrum happy and healthy!

Yoga and the Sacrum

by Shari

Nina asked me to expand a bit on Baxter’s previous post on sacroiliac challenges with asana practice (see Friday Q&A: Sacroiliac (SI) Joint Injuries). I wanted to start by giving a little more background on sacroilac anatomy. As Baxter previously stated, the sacrum is nestled in between the two ilia bones that comprise the pelvis. The front of the pelvis is the symphysis pubis and the back is where the sacrum is located.

The sacrum is affected by many different forces. Along with the pelvis, it forms the bridge between your head, spine, torso and arms with your legs and feet. All forces from the top of your body pass through your sacrum and out to your lower limbs, and at least sixty muscles directly or indirectly affect the sacrum.

However, the sacrum does not move on its own but moves only because of the connections it has to the two ilia bones as well as the muscles that either directly insert onto it or cross over it. This means that the sacrum can only be passively moved. The sacrum’s passive motions caused by muscle action directly onto the pelvis and coccyx (think pelvic floor muscles also) include pivoting (forward and backwards motion) and rocking (spinning on a certain axis).

When you go into a yoga pose, how you set your legs and pelvis up is going to directly affect forces on your sacrum. So if you are turning your pelvis to the right, unless your legs are in the same direction as your pelvis, your sacrum will get conflicting forces through it. There are too many muscles to go into in here, but it’s important to understand that the leg muscles that cross from your pelvis to your femur and the abdominal muscles that attach to your pelvis will have a profound affect on the position of your sacrum. The spine also has a direct effect of moving the sacrum, especially L5 (the lowest of the five lumbar vertebrae) as well as the two ilia bones.

Why the sacrum is so important for yoga students is that we put undue strain on the ligaments that are firmly holding the sacrum in place with the two ilia and on the ligaments that hold the sacrum to the L5 vertebra, particularly when doing asymmetrical poses. And one of the main muscles that has a direct affect on the sacrum is the pesky piriformis. Now why, of all the 66 muscles, am I singling out the piriformis? Well it is one muscle that many yoga students have heard about, and it is one of the main muscles that we stretch when we do Thread the Needle or Figure Four pose. The following figure shows the muscle in red (and you can see how it connects the sacrum and to the leg):

That's it for now! Tomorrow, we'll look at how the sacrum and sacroiliac joints work in some typical yoga poses (see Keeping Your Sacrum and SI Joints Happy and Healthy). Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

Knee Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s previous post Arthritis of the Knee and Yoga about what the next step might be when your own self-care management techniques are not as effective and your quality of life is severely impacted. So I thought I would you give some background about the elective procedure total knee replacement and why you might elect to have it done. Professionally, I see a lot of total knee replacements in my work as a home health physical therapist, and I also have yoga students who come to my class either after the procedure or beforehand as they are preparing themselves for the surgery.

Although many people will never need surgery for arthritis of the knee, if you have severe joint damage, extreme pain that isn’t helped by other treatments, or very limited motion as a result of the condition, knee replacement surgery may be necessary. So if the arthritis pain in your knee worsens, and the exercise that once helped you feel better has become unbearable, your doctor may recommend a total knee replacement (TKR). Surgery for osteoarthritis can provide several benefits, including :

• improved movement
• pain relief
• improved joint alignment

When you research the procedure, you will discover there are gender-specific knees, which are knee replacement models designed for women, and dozens of other options, too, including different materials, sizes and models from a variety of manufacturers. How do you choose? Generally, you don’t. Surgeons typically determine which implant they’ll use when they are in the operating room and actually looking at the structure and size of your bones.

X-Rays of Knee Replacements (from Wikimedia)

Prior to surgery, however, you should have an informed conversation with the doctor about your options so you can ask good questions about why a particular model might be chosen, and determine if you’re comfortable with the doctor’s approach and experience or whether you’d like a second opinion.

When only a portion of your knee has severe arthritic wear and tear symptoms, as confirmed by diagnostic testing as well as subjective complaints, you may be recommended to undergo a “partial or unicompartmental knee replacement.” This may be recommended because it helps to straighten up the joint, which has changed its position as a result of osteoarthritis. Partial knee replacement can be more effective and durable if appropriate and are less invasive. Recovery time is less because there is less surgical trauma.When the entire knee joint is replaced that is called a total knee replacement, and the ends of the femur, top of the tibia and often the patella (knee cap) are fully replaced.

When you are ready to return to your yoga class, you should take time to talk with your teacher about your knee replacement. I will routinely ask these students a series of questions:

1.    How long ago was the surgery?
2.    Are you still in pain?
3.    Are you still in physical therapy?
4.    Do you have any hip or back pain (either before or after the knee replacement)?
5.    How much mobility do you currently have? Can you get up and down from the floor?
6.    Do you have arthritis in any other joints?

So be prepared to provide your teacher with this information. Knee range of motion will vary widely both in a recent post-operative knee as well as a knee replacement that is over one year old. A lot depends on how much motion you lost prior to the surgery and how hard you worked postoperatively. The answer to the question “Can you get up and down from the floor?” is important because it tells the teacher a lot about a student’s flexibility and strength. Knee flexion will vary considerably, but I have never seen a knee replacement with 155 degrees flexion nor have I ever seen someone able to do a deep squat. Whether this just happens to be my student demographic or not, I don’t know.

When resuming yoga practice, alignment is a big deal with knee replacements because post operatively you want to avoid torque forces through the joint because that affects cement in the joint. “Closed chain activities,” where your weight is shifted with your foot remaining on the floor,” where your foot is lifted off of the floor with subsequent weight bearing will affect the joint differently. For standing poses, I teach students with recent knee replacements to pick their feet up and then replace and position as opposed to pivoting to change directions. Down the road, you can introduce pivoting if it doesn’t cause pain or discomfort. Liberal usage of props; walls, chairs, blocks will assist the student in not over-doing too quickly.

Strengthening all of the muscles that cross the knee joint as well as secondary stabilizers is also important. This means front, back and side leg muscles. Attention to hip alignment and strength also translates to protection of the knee replacement. Kneeling is problematic but not necessarily injurious to the new knee. Finally, pay attention to the feet—where is the weight on the foot? A lot of individuals who suffer from arthritic hips and knees have feet that need some tender loving attention. Baxter in his prior posts talked about feet (see Your Feet on My Mind), and I agree that where the body meets the ground and how we stack up from there is crucial in protecting our joints for longevity, especially when we become bionic.

I would like to add that lot depends on your pre-surgical state of health. If you have been active up till the day of the surgery then your recovery time will take about three months till you feel like you have integrated the new knee into your body. This is a rough estimate, but it seems about right for a traditional total knee replacement. Minimally invasive and partial knee replacements have less trauma, so healing and function comes more quickly. For those individuals who have lost a lot of mobility and have developed severe range of motion loss and significant loss of muscle strength, the recovery time will be more arduous because of all the structural as well as cardiac changes.

Finally I want to emphasize this: talk to your surgeon before and after surgery to know what your particular limitations and precautions may be, and remember to share them with your yoga teacher. Remember this is an invasive surgical procedure and everyone heals in a different manner. Be kind to yourself and remember that with a lot of hard work you will regain function and improve the quality of your life. This the reason why you decided to undergo this surgical option in the first place.

Total Hip Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s post Arthritis of the Hip Joint about what the next step might be when your own self care management techniques are not as effective and your quality of life is severely impacted. I thought I would give some background about the elective procedure of total hip replacement and why people might elect to have it done. I see a lot of total hip replacements in my work as a home health physical therapist, and I also do have yoga students who come to my class either after the procedure or before hand as they are preparing themselves for the surgery.

X-Ray of Hip Replacement from Wikimedia

As background, here is what the Mayo clinic says about hip replacement surgery:

"Hip replacement surgery, also called total hip arthroplasty, involves removing a diseased hip joint and replacing it with an artificial joint, called a prosthesis. Hip prostheses consist of a ball component, made of metal or ceramic, and a socket, which has an insert or liner made of plastic, ceramic or metal. The implants used in hip replacement are biocompatible — meaning they're designed to be accepted by your body — and they're made to resist corrosion, degradation and wear.

The goal of hip replacement surgery is to relieve pain and increase the mobility and function of a damaged hip joint. If a stiff, painful hip joint has forced you to cut back on everyday activities, successful surgery may allow you to resume them. Conditions that can damage the hip joint, sometimes necessitating hip replacement surgery, include:

• Osteoarthritis
• Rheumatoid arthritis
• Broken hip
• Bone tumor
• Osteonecrosis, which occurs when there is inadequate blood supply to the ball portion of the hip joint

To perform a hip replacement, your surgeon:

• Makes an incision over the front or side of your hip, through the layers of tissue
• Removes diseased and damaged bone and cartilage, leaving healthy bone intact
• Implants the prosthetic socket into your pelvic bone, to replace the damaged socket
• Replaces the round top of your femur with the prosthetic ball, which is attached to a stem that fits into your thighbone

Your new, artificial joint is designed to mimic the natural, gliding motion of a healthy hip joint. "

Artificial Joint from Wikimedia

Techniques for hip replacement are evolving. As surgeons continue to develop less invasive surgical techniques, the hope is that these techniques might reduce recovery time and pain compared with standard hip replacements. However, studies comparing the outcomes of standard hip replacement with those of minimally invasive hip replacement have had mixed results.

Choosing an orthopedist to perform your surgery is a very personal decision and we all research our concerns in different manners. Please, though, when you have found a surgeon that you want to work with, make sure you discuss the different types of hip replacement surgeries that they may perform so you understand clearly the advantages and disadvantages that each surgical procedure presents. Be particular that the surgeon understands your own particular yoga practice and what it entails. Bring pictures of poses that you currently do (or have done) and make sure the doctor understands the stresses you place on your hip joint. Telling a physician who doesn’t do yoga “I do yoga” isn’t enough, so show him or her the positions your hip needs to be able to move through.
The surgical options that exist are very different in what the post operative limitations are and the longer standing limitations that the post replacement hip might present you with.

The basic categories of total hip replacement are either:

• posterior lateral approach
• anterior lateral approach
• anterior approach
• minimally invasive anterior approach or minimally invasive posterior approaches

These are all different, but as far as hip precautions go there are no hip precautions for the anterior approaches.

Now this important for the practice of yoga. Which approach is recommended for your particular situation is going to affect your asana practice. Please ask your surgeon what your post-operative physical limitations are and for how long. Make sure you learn how to safely get up and down from the floor so as to not dislocate your new hip and that you learn the specific precautions associated with your category of hip replacements. The key is that you learn to identify what position is your hip in when you do your poses and you need to think of both legs when you do each side (don’t just focus on the surgical side).

In the more traditional posterior or posterior lateral approach there are limitations on hip flexion, adduction and internal rotation. That means that if you combine these three positions you are more apt to dislocate your prosthetic hip because the muscle support is weakened by the surgical procedure. That is definitely going to affect your asana practice. Poses you might want to not do for approximately six months would be: Standing Forward Bend (Uttanasana), Eagle pose (Garudasana), Cow-Face pose (Gomukhasana), and Child’s pose (Balasana). Gentle backbends generally are okay for posterior/posterior lateral hips.

For anterior lateral hips the precautions will be very different. Typically hip extension and hip abduction will be affected and you don’t want to be aggressive in these combined movements. So start thinking about your backbends and standing poses. Remember that the position of the front and the back legs are very different in the standing poses. The front hip may be placed into positions of flexion and external rotation and abduction but the back hip may be in extension with external rotation.

For anterior hip replacement surgeries the doctor will typically tell you that you have no restrictions but that doesn’t mean you are going to jump back into your asana practice. The hip is going to be sore and painful because of the surgical trauma (though it is less in this procedure than some of the other ones I talked about because there is no actual muscle cutting in this procedure but the muscles are certainly stretched as they are moved for the surgery).

So now armed with your knowledge of what type of hip surgery you have had, and what your physical restrictions are and for how long, consider the critical importance of studying with a teacher who can assist you in practicing safely. Knowing what props to use and when are important, and so is knowing how deep to go into a pose. In addition, different surgeries have different time frames for returning to asana practice but the rule of thumb to return to any activity post operatively is how you feel. You can get time estimates on when to resume an activity but the bottom line is your own healing process and energy level. As always respecting your energy level and not be overly aggressive as you return to your asana practice is crucial.

In my clinical experience I have never had a client tell me that he or she is sorry to have undergone this surgery. In all medical procedures, knowledge, mental and emotional preparation and conviction in your choice of action go a long way towards healing. That certainly sounds like an engaged yoga practice off of the mat!