Pain in the Neck? Try Yoga.

April 18, 2013

Standing Forward BendA lot of information is available about low-back pain, a topic I’ve covered here. But less attention is paid to neck pain, despite the fact that as many of two-thirds of adults experience it.

Neck, or cervical, pain, can stem from a variety of causes, including serious concerns such as trauma to the vertebrae, ruptured discs, or infection. These are conditions that must be evaluated by a doctor, and I would recommend avoiding activities like yoga while in treatment.

But yoga can be incredibly helpful in addressing the less complicated causes of chronic or occasional neck pain,  brought on by things like tension, poor posture, minor neck strain, occupational and sports injuries.  The structural changes that lead to the pain are usually soft-tissue (muscle, ligament, tendon, disc, cartilage) abnormalities due to injury, or prolonged wear and tear on the vertebrae.  And for many people, neck pain results from tightness in the upper back, shoulder, and arms.  When the neck pain has been around long enough, it is reclassified as chronic, and the same underlying mechanisms of injury, with secondary scar tissue, and degenerative changes on soft-tissue structure, as well as the added changes to bones, contribute to the persistent nature of the pain.

The first line treatment for neck pain usually involves ice or heat, anti-inflammatory medications like ibuprofen, and rest.  If the pain lingers, the non-surgical treatment (and don’t we all want to avoid surgery) can then include physical therapy.  What are so interesting about this added treatment are the reported goals of physical therapy: strengthening and stretching weakened or strained muscles, postural therapy, and cervical traction—which also happen to be the benefits of a balanced, beginning-level yoga practice!

Time and time again, my students who complain of neck pain at the start of class report improvement in their symptoms by the end of class.

How Yoga Helps

Let’s start with postural alignment.  When we do Mountain Pose, as we do in almost every class, we do it with great attention to detail regarding our posture.  We use language like “place the shoulders over the hips and float the head evenly over the shoulders” to re-align the standing position if we tend to sag, list, or jut out of good alignment.  For some of us, this will immediately require that we strengthen some muscle groups and stretch others to maintain this neutral, beneficial way of standing.  And then we take this new awareness into poses like High Lunge, Plank, and Downward Dog by asking ourselves to find and keep the neutral position of the neck and head relative to the rest of the body.

Many poses will help to strengthen the muscles that flex and extend, sidebend, and rotate the neck.  And while one side of the neck is experiencing strengthening of a muscle group, the opposite side is usually doing a bit of the opposite, which is to say, stretching.  Examples of this include Cobra and Locust poses, which strengthen the back of the neck while stretching the front, Boat Pose for the front of the neck while extending the back, Triangle when performed looking forward, so that one side of the neck is strenthened while the other stretches, and Side Angle Pose done looking up, to strengthen and stretch the muscles that rotate the neck.

That leaves the idea of traction for last.  One of the simplest and probably safest ways to create a gentle traction for the soft tissues of the neck is to hang the head  and release into the pull of gravity.  This is nicely accomplished via Standing Forward Bend and Downward-Facing Dog.  In Uttanasana, I usually suggest that students with tight hamstrings bend the knees a bit to help release the head and neck more directly toward the floor.  With Down Dog, it is wonderful to have a partner place a strap around the upper thighs standing behind you, lean back and take on some of the work of the legs and arms for you, so you can more fully release the neck, not push it, toward the floor.

And be cautious during active times of neck pain with poses that obviously put extra pressure on the neck, like Bridge, Shoulderstand, Headstand, and Fish.  With the exception of the first one, the others are more advanced poses and are best left to times the neck is pain-free.

And don’t wait too long to have your family doc check you over thoroughly if your neck pain is not improving in a reasonable amount of time.  In the meantime, a mindful yoga sequence could be a nice supplement to your healing regimen for neck pain.

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Yoga for Musicians

February 14, 2013

flute player at yoga classIn a recent three-day span, I had the several students of mine who are also the moms of aspiring musicians ask if I had any advice for keeping the young virtuosos’ healthy.  They all expressed a similar concern: that the body positions that their children had to assume to play their instruments seemed potentially damaging.  And especially since they were practicing sometimes up to six hours a day.  I am sure pictures of aging rock and roll stars didn’t help either, with the collapsed look of Keith Richards, or the rounded back of most older drummers.  Well, yoga practices are not only good for the body of the musician, but probably for the musical mind as well.

The first thing to acknowledge is that most musicians who play an instrument adopt a posture that is usually somewhat asymmetrical, and sometimes dramatically so.  This is obvious with guitarists and violinists, as examples, where one arm is doing one thing and the other something else.  It is subtler with some instruments, like the clarinet, for example, where the only shift is that one hand is always above the other.  And it might look like the drummer could keep things even, but one of his feet is usually forward to push on the petal of that bass drum.  And almost all musicians tend to round the upper back, either to read music from a music stand, or from sitting in chairs to play.  And, again, if they are practicing for long periods with few breaks, it is likely that their posture will begin to collapse from fatigue.

The yoga asana practice could help to balance out these functional changes that arise gradually over time for most musicians.  From the simplest focus on Mountain Pose, to easy mini vinyasa sequences, like inhaling the arms overhead and exhaling them back down, yoga offers the opportunity to keep the body as healthy as it can be.  And because the arms are almost always below the level of the shoulders for musicians, doing yoga poses that get the arms to reclaim their full range of motion are essential.  My favorites, as a violinist since age 5, include Warrior I and II, Triangle, Eagle arms, and Cow-Face Pose arms, especially the top arm variation.

For the tendency to round in the upper back, or to become more kyphotic, I like to prescribe reclining supported backbends, like a roll under the shoulder blades, supported Bridge, as well as Cobra, Sphinx and Locust.  I like to do these poses dynamically, rhythmically coming in and out of the pose with my breath, which should appeal to the syncopated musician out there!  And I also like to hold these poses for 6-12 breaths to work on improving strength and endurance in the muscle groups that are usually a bit weak from rounding forward all the time.

And all of the poses that move the legs into extension, like the back leg in Warrior I, are great antidotes for those players who tend to play seated most of the time.  And reminding these songsters to take regular breaks in their practice schedules to do little mini yoga practices will keep the body and the mind more fresh and present.

Last, but certainly not least, the mental benefits of yoga asana, pranayama and meditation could lead to improvements in performance for both aspiring and established musicians.  Yoga meditation practices seem to support the creative process, and also help to improve mental focus, which should help out those classically trained players trying to memorize pages of Chopin or Bach.

 

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Change Your Diet With Yoga

January 31, 2013

woman about to eat an appleI recently asked a group of students to identify motivating reasons to improve their eating habits.  I love the collective wisdom of a group, and this lively gathering was no exception.  Obviously, a desire for weight loss was near the top of the list, but also its opposite, the need for weight gain was suggested (a common complaint for those with chronic illness or undergoing cancer treatment).  Other reasons included healthy eating to deal with food allergies, gluten sensitivity or intolerance, specific conditions of the digestive system like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) such as Crohn’s disease. Also, noticing that your usual diet leaves you feeling poorly after eating.  Or noticing that an adopted diet, like Atkin’s, causes unwanted and worrisome symptoms.  Another personal motivation might include discovering you have early stage diabetes or high cholesterol, and hope that a change of diet could help.

Identifying a reason to develop healthier eating patterns could be considered setting your intention, or as we say in yogaspeak, your sankalpa.  This can be a pivotal moment and a touchstone that you return to as you work to change your habits.  In some ways this is the easy part.  It’s the instituting and maintaining of the new habits that is always a challenge.  Some of the key skills that doing yoga regularly develops include learning to recognize which foods are good for you and which are not; when you’re satisfied, which is different than feeling overly “full”; when you are experiencing thirst, not hunger; and when you may be eating due to stress. All of these insights are revealed via the cultivation of moment-by-moment awareness that happens during the hatha yoga practices of asana, breathwork, and meditation.

Meditation, in particular, seems to be quite effective in helping us maintain the healthy changes we might make to our eating.  In her recent book Willpower, and in the program Boost Your Willpower that she created for Yoga Journal, yoga teacher and psychologist Kelly McGonigal explains about how mindfulness practices like meditation, and potentially yoga asana practices done with mindfulness as a main focus, do just that. For example, studies indicate that ongoing meditation practice increases blood flow to the prefrontal cortex of the brain, the area associated with impulse control.  And just like you’d do curls at the gym to make your biceps stronger, meditation is the exercise that makes your impulse control, and therefore your willpower, stronger.

Another interesting finding from modern science that helps us understand how we get tripped up so easily when we are under stress is that our brains have a hard time distinguishing between real danger and our modern forms of stress.  Our background operating systems react similarly to a life-threatening situation and say, an argument with a co-worker: the body releases chemicals that liberate fuel into our bloodstream so we can get away from danger quickly, and later releases cortisol, which stimulates hunger, so we can replenish the fuel we just used up.  The problem is that after the argument with our co-worker, we rarely immediately go on a fast run, so when the second phase of the body’s autoresponse kicks in, cortisol release, and we get hungry, we end up eating even though we don’t need the fuel.  This is one way stress can lead to unwanted weight gain.

The initial stress response also lowers impulse control (the very thing meditation improves).  We need to be a bit impulsive and spontaneous when confronted with real danger.  Not so much so with most of our modern stressors.  So these stress episodes tend to be the times we are most likely to revert back to our unhealthy habits, and in this case, unhealthy patterns of eating.

Fortunately, yoga has been noted in many studies to have a positive effect on lowering the stress reaction. When we are less reactive in stressful situations, we can make better choices in the moment. And, finally, the physical practices of get you moving and using up some of your fuel stores (as if you really were running from a bear).

And what do you do when, while meditating, you notice unhelpful thoughts arising?  Patanjali’s Yoga Sutra 2.33, vitarkabadhane pratipaksabhavanam, translated by Edwin Bryant as “When disturbed by negative thoughts or events, cultivatation of opposite thoughts or events” (tr. Nicolai Bachman) provides useful advice about what to do when it becomes obvious that your thoughts are pulling you back into old, unhealthy patterns of eating.  As modern spiritual teacher Byron Katie suggests, flip that negative thought around and if it’s positive opposite isn’t as or more true than the original.

Armed with modern science and ancient advice, your healthy eating intentions for the New Year can become a reality!

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Men and Yoga

January 10, 2013

man in Tree PoseIn late December, The New York Times science writer William Broad, author of the controversial book The Science of Yoga, penned an article outlining the inherent dangers of yoga for men.

My purpose here is not to refute this article, but for more information that does that, you might look for recent online posts by Timothy McCall, MD, and Ram Rao, PhD.

However, I do want to say that in my experience as a yoga teacher and health-care professional for well over a decade, I have not observed this injury trend that Broad believes is afoot.  Just the opposite: In my teaching across the country, I receive many more reports from men of the benefits of their regular yoga practice.

To this I would add a few points:

1. The potential benefits of appropriate yoga practice will far outweigh any risks.  So, if you haven’t already, get on the mat!  For a thorough discussion of this topic, see “Practice Awareness” in the February issue of Yoga Journal.

2. Articles like Broad’s tend to reduce “yoga” to mere asana practice or physical poses.  And although this is the trend in some studios, I would encourage those of you interested in a more complete experience of yoga to look for classes and studios that embrace the full spectrum of what yoga has to offer: physical practices, breathing techniques, accessible meditation teaching, as well as community building and opportunities for selfless service.  As Jon Kabat-Zinn, leading voice in mindfulness meditation for stress reduction, says, yoga is about developing ongoing attention to what is really happening in your body all the time. And developing this kind of awareness makes it far less likely that you’ll injure yourself during yoga practice.

3. I would recommend you see your yoga as one part of a multi-pronged approach to your health and lifestyle, as opposed to substituting asana for all of your exercise.

4. If you are worried about hurting yourself, start with an entry-level class (that’s right, a beginner’s class), with a certified, experienced teacher.  Once you have learned some basics, you can gradually advance the difficulty of your yoga asana practice, if that is a reasonable goal for you.  And you must check your competitive tendencies at the door.  Save those for the basketball court or the golf course, where they may be more appropriate.

5. With the unrelenting stress of the past several years and the accelerating pace of our technologically oriented lives, now, more than ever, it is important for men to have access to the calming, centering, opening, strengthening, stress-reducing benefits of a regular yoga practice.  In some ways, the concern should not be whether yoga is more injurious for men than women, but how do we get our men into yoga in the first place.  For a pretty thorough look at this challenge, check out this article by Andrew Tilin.

6. As yoga consumers, you should insist that your local studios hire the best trained and experienced teachers they can, and support the efforts of organizations like the Yoga Alliance and the International Association of Yoga Therapist that are involved in developing and improving training standards for teachers and schools of yoga.  In this balanced way, you are taking care of yourself and encouraging the yoga establishment to evolve and improve what it has to offer you.

7. We could definitely use more truly scientific studies to better understand the benefits and limitations and risks of yoga, especially yoga asana. The question often comes down to “where will the money come from?” to fund such research.  As activist consumers, letting your elected representatives know this a priority to you could result in more support for agencies like the National Institutes of Health, which is already funding some yoga research.

 

I sincerely hope that one of your intentions for the new year is to continue to integrate yoga into your personal health plan, along with cultivating a good diet, getting adequate rest and sleep, and participating in solid aerobic exercise.  I will do everything I can in these posts to support, encourage and inspire you on your ongoing yoga journey.  Happy New Year!

 

 

 

 

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Foot Position in Upward-Facing Dog

December 20, 2012

Upward-Facing DogI recently heard from someone who struggles with poses such as Upward-Facing Dog because of a fused ankle. The foot no longer goes into plantar flexion, which is the position you take after rolling over your toes and resting the top of feet on the mat with the soles facing upward.

It’s a common dilemma for yoga students who have sustained injury to the ankle, which either limits their ability to point the foot or to flex the ankle back in the opposite direction (called dorsiflexion).  When surgery is required, it improves the stability of the ankle for standing and walking, but doesn’t usually allow much range of motion beyond that. 

I learned a useful substitute for this plantar flexionI was studying yoga at the Krishnamacharya Yoga Mandiram in Chennai, India, we were instructed in Surya Namaskar, or Sun Salutations, we were encouraged to transition from Downward-Facing Dog into Upward-Facing Dog without doing Chaturanga Dandasana.  And because we were inhaling into Up Dog and exhaling right back into Down Dog, we were told to keep the toes turned under and the ball of the foot on the floor, such as in the back foot in a High Lunge. (See photo below.)  It was just so efficient!  Up Dog with Foot Flexed

I came to appreciate this variation so much that I did it more and more in my home practice and started teaching it to my students as well.  In the case of a fused ankle, this variation works beautifully!  You keep both ankles, feet and toes in the lunge position.  And of course you can hold this variation for several breaths, just as you would the top-of-the-foot version.  I would recommend that you also press the heels strongly back while in the pose to keep the legs more active as a support for the overall shape of Up Dog.  You can even set up with your feet near a wall and press your heels into the wall to train the feet and legs to maintain this sort of directional action when you are doing the pose in the middle of the room.

I have also found that using the yoga wedges as a lift and support can also be helpful, especially under the ball of the front foot in poses like Triangle, where the front ankle, again, needs to able to point, or plantar flex, to get the entire foot grounded.  This way of supporting the limited range of motion of the ankle joint could also be helpful for those suffering from the much more common ankle sprain, which requires limiting movement in the recovery period until the swelling subsides.

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Does Headstand Cause TOS?

December 6, 2012

headstandA surprising number of yoga students have told me they have been diagnosed with Thoracic Outlet Syndrome (TOS), as a result of their headstanding practice.

Now while it’s certainly possible that Headstand, which involves flexion at the shoulders in the direct area where the thoracic outlet is, could trigger an existing injury or even cause TOS, there may be other factors at hand. And a diagnosis of TOS doesn’t mean you have to give up yoga, either.

First, what is Thoracic Outlet Syndrome? TOS occurs when the blood vessels and nerves in the space between your collarbone (clavicle) and the first rib—the thoracic outlet—are compressed, causing pain in the neck and shoulders, and numbness in the fingers. It’s typically caused by things like poor posture; pressure on the joints (like from carrying a heavy purse or backpack); trauma, such as from a car accident; repetitive activity, such as on the job or from sports; pregnancy, which loosens joints; and anatomical things like having an extra rib. Still, sometimes the cause of TOS isn’t known.

Usually any condition that carries the term “syndrome” means that on some level, we Western doctors can’t always nail down the exact source of the problem.  With TOS, sometimes X-ray and nerve and blood flow studies can point to a definitive cause, like that extra rib.  Interestingly, a family member of mine, an active athlete and avid golfer, fell and hit this area of her shoulder and developed TOS.  Because a blood clot formed in one of her veins, she opted for surgery.  Many people with the condition don’t have to go to that extreme, and will improve with physical therapy and medication.  Oddly, this same women was found to have TOS on the side not affected by the fall, and had both sides operated on.  So her fall alone did not explain her TOS.  Other factors were likely in play, both anatomical and physiological.

There are several kinds of TOS: neurogenic (neurological) thoracic outlet syndrome, caused by pressure on the Brachial Plexus, the network of nerves from your spinal cord that control muscle movements and sensation in your shoulder, arm and hand; vascular thoracic outlet syndrome, caused by pressure to the blood vessels that travel through the area; nonspecific-type thoracic outlet syndrome, where an exact cause is hard to pin down, but symptoms are present.  This last type is controversial, as some docs believe it exists, while other don’t.

Now, back to yoga students with TOS. The thing that drives most people to seek medical help is pain, and in the case of TOS, pain and numbness, sometimes weakened hand grip.

In general, patients with TOS often notice symptoms the most when the arms are lifted above the head, as the delicate structures in that thoracic outlet could theoretically get compressed in that position.  Often, the pain and numbness will subside or resolve completely once the arms are lowered to at least parallel with the floor.  Since Headstand does involve the arms in flexion at the shoulder joint, or essentially overhead if you were to recreate it standing up, it is very possible that Headstand could bring on the symptoms.  And oftentimes students haven’t developed enough strength and space in the shoulder joints to prevent compression of the thoracic outlet before attempting the pose.

If the student’s symptoms only come on in Headstand, I’d recommend eliminating that pose, at least temporarily, and seeing what happens.  If other poses done with the arms overhead, such as Warrior 1, or even Handstand, don’t trigger symptoms, then there could be other explanations, like cervical disc problems, that could be the underlying cause.  If the tests done to identify an underlying anatomical cause of TOS were normal, I might get a few other opinions before scrapping any future attempts at a full yoga practice.  The good news, of course, is that there are a huge number of other poses to do that could be equally satisfying, even if you have to leave a few out.  As always, working with an experienced teacher will keep you in the yoga!  And as one of my senior teachers once proclaimed when a student bemoaned the fact of not being able to Shoulderstand anymore, “No one ever got enlightened from doing Shoulderstand!”

I’d have to say the same goes for Headstand.

 

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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When Hamstrings Hurt

November 8, 2012

UttanasanaI’d like to address a common injury to the hamstrings, those powerful muscles in the back of your thighs.  It is not unusual for students who don’t warm up the hamstrings slowly, who push themselves in hamstring-stretching poses, or who do a lot of jumps into and out of forward bends and Chatarunga, to injure this area in the form of strain from overstretching, or, in more serious cases, tearing of the muscle fibers.

The hamstrings all start off from the same starting point, your sitting bones or ischial tuberosity, and head down toward the knees.  They comprise three muscles—semitendinosus, semimembranosus and biceps femoris—and their corresponding tendons.  The semitendinosus and semimembranosus split off to the inside back of the lower leg bone at the knee, and the biceps femoris heads to the outside back of the lower leg at the knee.  So the hamstrings cross two joints, your hip joint and your knee joint.  When the they contract, they can either pull you upper leg, the femur, back behind you into extension, or they can help your knee to bend or “flex,” or they do both things at once.

If you have your femur pulled back and your knee flexed, like in Dhanurasana (Bow Pose), your hamstrings are at some of their most contracted and shortened.  When you are bending forward at the hips in poses like Paschimottanasana (Seated Forward Bend), they are required to go to their maximum length or stretch.  And when you are springing back for Uttanasana into low Plank, or springing forward from Down Dog to Uttanasana, your are putting a sudden intense demand on the hamstring muscles.

The vulnerable and most commonly injured area is where the muscles originate at the sitting bones. The short tendons that anchor the muscles to the bone heals most slowly, due to a poor blood supply.  Once present, this injury can take a long time to heal.  In addition, once the injury has occurred, it gets aggravated by any stretching of that muscle, which can delay healing even more.  Since stretching the hamstring is detrimental to healing, at the very least, you will need to modify (by bending the knees deeply) or skip all forward-bending poses until the inflammation in the tendon (and the accompanying pain) has disappeared.

As you can imagine, this would likely preclude you doing vigorous vinyasa practices without the very likely chance of re-injuring the tendon again and again.  In addition, more static styles of practice like Iyengar or Anusara yoga would need to be modified if forward bends are part of the sequence.  I learned a trick from one yoga teacher for modifying the front leg in Triangle to eliminate painful pulling of the hamstrings.  Instead of turning the front foot out 90 degrees, you would turn it out more like 100 degrees or so.  This would shift the stress more laterally on the tendon, to an area that might still be healthy and intact.

Your yoga strap can be of some help as well.  Make a loop and place it snuggly up the thigh as high as you can and so it won’t slip down (but not too tight). This creates a kind of brace that will shift the stretch of forward bends to the strapped spot on your hamstrings and away from the sitting bone.

Roger Cole recommends that post injury, you rest for at least 72 hours to let the inflammation cool down, then focus on strengthening the hamstrings before returning to forward bends.  This can be accomplished beautifully by Locust Pose (Salabhasana), and I like to have students do a one-legged version, where the affected leg is lifted just few inches off the floor, keeping a sense of the leg lengthening backward.  Warm up with a dynamic version, inhaling up and exhaling down for 4-6 breaths, before holding the pose for a few breaths.  If this causes any pain, you probably need to rest the area for a while longer.

Hamstring injury requires patience with your body.  It can take months of slow, methodical work to allow the area to heal to the point of returning to a regular class.  And even then, you’ll need to spend some time at the start of each practice warming up the hamstring muscles before diving into a vigorous and strong asana sequence. Once injured, this area will be vulnerable to re-injury, so being mindful about your actions and your body will help you keep it healthy and your practice strong.

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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The Core of the Matter

October 25, 2012

Plank PoseBy Baxter Bell

In part 4, the last on my posts about back pain, I want to address what we often refer to as “the core,” and its role in protecting your back.

There’s a belief that having good “core strength” lessens the chances of injuring your low back and could aid in healing injury there.  I hear this all the time from my friends who are Pilates instructors and often read it in articles about what people can do to protect their backs.  But as far as modern research goes, there is no compelling evidence to support this assertion.  Core-strengthening exercises are no better or worse than other forms of exercise that have been shown to be helpful for low-back pain.  Before we go throwing the baby out with the bath water, I should define what I consider “the core.”

In my view, the core musculature comprises the four abdominal muscles (the rectus abdominis, the internal and external obliques, and the deepest layer, the transversus abdominis).  Also, the psoas and iliacus muscles, the quadratus lumborum, the deep back muscle layer which includes a group known as the multifidii, and the intermediate back muscles known at the erector spinae.  To top it off, the diaphragm and the pelvic floor muscles can be included in a complete vision of the human core.  Three-dimensionally, this includes the front, sides, back, top and bottom of this area of the body.

If you have a balanced yoga asana practice, in all likelihood you will have a fairly balanced and strong core, and it’s probably unneccessary to do additional core strengtheners, many of which have almost identical yoga equivalents: drop knee lunges like we use as preps for Warrior 1 and deeper backbends;  dynamic reclining versions of Supta Padangusthasana; dynamic Cat-Cow to Child’s Pose; Forearm Plank; Forearm Side Plank (Vasishtansana);  Dynamic Cobra and Locust variations; Dynamic Bridge, and so on.

And even the extra core focus in or out of yoga class may be unnecessary, again, if your yoga practice is balanced. For example, I don’t ask my students to walk around with Mula Bandha engaged all the time, or to activate the transversus abdominis while driving.  My feeling is that you strengthen these things via your practice, and then you move into your life without having to suck in your gut or tuck your tail while doing your daily activities. You allow these strengths and openings to be in operation in the background of your awareness.

But do I think these poses and other core strengthening exercises are reasonable? Sure.  What they don’t offer, however, and what yoga does (at least in my classes) is use bandhas and pranayama to positively influence the diaphragm and the pelvic floor muscles in addition to the dynamic and strengthening aspects of yoga asana.

In addition, in my back-care classes I teach a different variation to the “yoga sit-up” you may have encountered in some of your classes.  Often, instructors will have you flatten your lower back on the floor as you do variations that look like a Western style sit-up.  I prefer a small natural arch in the lower back that you maintain without letting it change as you roll your head and upper back off the floor a bit on your exhale (lower tips of the shoulder blades remaining on the floor), and lower back down on the inhale.  I am assuming that the natural lumbar arch present when standing is architecturally the most stable for the most sensitive structures, such as the discs, nerves, and joint surfaces.  So, I make sure it is here in the reclining position.  This would seem to activate the deepest abdominal layer, the transversus, very effectively, as well as the deep back muscles.  The vast majority of my students find this method accessible and comfortable for their backs.

My recommendations for low back pain and core strengthening are these: familiarize yourself with contemporary CS exercises and the yoga equivalents, and integrate some into your home practice.  Also, do a good balanced yoga practice that has something from each of the different categories of poses (standing, sitting, inversions, etc.), and include some basic pranayama, and engage the lower two bandhas.  And if a particular pose hurts your back, eliminate it, at least until you can have your teacher review your technique for any obvious glitches.  Add in walking or any other form of physical exercise that you enjoy (both physically and mental/emotionally), that does not aggravate your back.  And enjoy the process!

For those interested in learning more about the lack of good evidence for CS and back pain, search Google for an article called “The Myth of Core Stability,” by Eyal Lederman.

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Yoga for Back Pain, Part 3

October 11, 2012

On a recent flight home from a weekend workshop in Wyoming, as I sat in the oh- so-comfortable seating of one of our major airlines, I decided to peruse the SkyMall magazine that can be found in every seat back pouch of every plane in the country.  I am always wondering if there will actually be something in there that I cannot live without.  Of course, the last time that happened was about 15 years ago, and I still use the nifty wallet I got to this day.  But what jumped out at me, as I squirmed to stay comfortable on hour two of my flight, was the number of devices for all sorts of health issues—most notably, for low-back pain.  There were at least a half dozen different gizmos to help you cure your back pain, and you could easily drop $500-600 if you got them all.  A recurrent theme for many of the devices was a way to create traction on your spine as a way to reduce low-back pain.

The pages of SkyMall are not the only place where you can find traction prescribed for improving LBP. In fact many medical offices dealing with low-back pain, like your neighborhood chiropractor, may have a very fancy table and set up to do just that. Despite the lack of scientific evidence that traction as a single form of treatment for low-back pain is effective, many students find the yoga suggestions below helpful in a multi-pronged approach to the problem. I had a friend with such pain, who after trying a lot of other things, swears that the weekly table traction he got at his chiropractor’s office finally did the trick. His only complaint was the cost: a lot!

As I’ve discussed in my past few posts about studies on back pain and easing it with yoga, your practice can provide you with safe, gradual traction to relieve tight muscles and connective tissue in the low back and possibly improve the space between the lumbar vertebrae. And at much less the out-of-pocket cost!  Some of the poses you already do, if done mindfully with an eye to not triggering any low-back pain while in them, could be helping to create some traction already. Poses like Downward-Facing Dog and Standing Forward Fold, with a slight bend to the knees for both to allow the pelvis to create most of the forward folding action over the leg bones, can allow for some traction on the lumbar spine. If you have a history of a bulging or herniated disc, you should check in with your doctor before doing these poses  regularly.

What works really nicely and gives more traction for the entire spine, is to do a version of Down Dog that involves a partner standing behind you, holding a strap that is placed across the top of your thighs. As you go up into Down Dog on your own, the partner will pull the strap firmly against your thighs while leaning back. This allows your arms to become almost unnecessary in keeping you in the pose.  Your main job becomes cultivating the feeling that you are lengthening your spine away from your legs in the direction of your hands. Your partner anchors you up and back at the thighs and gravity pulling your forward and down does the rest to create traction for the spine. Stay for up to two minutes. Always take a minute or so when you come out to see how the back responds to this. If you feel good afterwards, it is usually safe to proceed further.

If you don’t have a friend that can do this with you (although I highly recommend you train one to do so) you can use a sturdy doorknob and a long yoga strap to accomplish the same thing.  Make the strap into a non-slip large loop, thread it around the inside and outside doorknob of an indoor door, with the door open into a room you can practice Dog into. Step your body inside the loop, holding it up against the top of your front thigh as you face away from the door.  Bend your knees, lean your weight forward into the strap, and drop your hands to the floor.  At this point you will likely walk your feet back a bit, so they will be on either side of the door, while walking your hands forward until you are in Down Dog, with the strap creating a good pull back on your thighs. In the partner and door versions of Down Dog, you can stay for up to two minutes if things are pain free. With the door method, bend the knees and walk forward away from door, and the body will swing up from the back pressure of the strap. If you have a “yoga wall,” you have likely played with this similar pose with your sling on the higher set of bolts.

With a yoga wall, you can also do a hanging version of Cobbler Pose, which really maximizes gravity’s effect on the spine. The only problem is that you need a very strong core to get in and out of that pose safely, so I will not describe it here, but next post I will address core strengthening and low back pain specifically.

One last idea: Position yourself close to a wall and lay down on your back about one shins-length from the wall. With your knees bent to 90 degrees, put your feet up on the wall so that your shins are parallel with the floor. You will have a nice 90-degree bend also at the hips and thigh bones. Here you can place your hands on the thighs down by the root of the legs. Push your hands into the thighs directly toward the wall. This will create a kind of secondary traction on the spine as your hands move your thighbones away from the pelvis and the pelvis gets pulled along for the ride. Again, maintain the push for up to two minutes, or as tolerated. and assess how it feels after you come out of pose.

As with all practices, as long as your back is not feeling worse after your yoga traction experiments, you will want to do these variations regularly over the course of a few weeks or longer to establish ongoing benefits.

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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Yoga for Back Pain, Part 2

September 13, 2012

seated twistA colleague of mine recently made the observation that you never hear your friends and family telling you how great their back feels. In fact, it is usually the opposite sentiment if they mention the back part of the body at all. And yet, as my last post pointed out, yoga is proven to provide relief for chronic back pain of many kinds. The sensation of well-being for a formerly in-pain student is likely a main reason people return to yoga class week after week.

It’s common to see among new yoga students chest-fallen spines, tucked pelvises, and forward-jutting heads. Called kyphosis, lumbar lordosis, and Head Forward Syndrome respectively, these postures are often either the source of back pain or the result of pain due to postural compensations you make to avoid pain. Meanwhile, we know that improving your posture helps to counteract the consequences of aging and gravity on the spine, such as diminished stature, decreased lung capacity, and even decreased abdominal cavity size, which can contribute to sluggish bowels and constipation, urinary frequency, and stress incontinence.  Yowser!  If you didn’t have a reason to stand more erect, you do now! And for students of all ages, good posture improves balance, lung function, general circulation to all of the body parts, and encourages normal spine architecture.

One way to assess posture is to look at the plumb line, the imaginary line that reveals your center of gravity and that passes through key anatomical landmarks. Looking at someone from the side (or yourself in a photo), start the line at the center opening of the ear, and draw directly down to the side of foot and see what other areas of the body this line bisects.  Ideally the line goes through the center point of your upper arm bone (the head of the humerus), the boney point or your upper leg bone near the hip joint (the greater trochanter), the center of the side knee joint (front to back center point) and the boney point of your outer ankle (the lateral malleolus).  Many people new to yoga, however, have points that fall in front of or behind the plumb line. Don’t get discouraged if that’s you; you can change this gradually with regular yoga practice.

One way to start working on getting back to center is to stand with your back, including your shoulder blades and butt, resting gently against a wall, but with your heels 4-6 inches away from it.  If you have already determined that you have a forward head position, don’t attempt to rest it on the wall at this time. Your yoga practice will begin to correct this situation gradually. If you notice that your upper thoracic (in the region of your ribs) spine is on the wall, but not your shoulder blades, you may have kyphosis. You can work on this by consciously widening your collarbones on the front upper chest away from the breastbone, noticing if the shoulder blades respond by starting to make contact with the wall behind you. If you notice that the low back and spine are flat on the wall, you may have lost the natural lumbar curve that typically leaves a small space between just your low back and the wall. Try bending the knees slightly and tipping the pelvis forward and down a little bit.  Does the space in the lower back suddenly appear?  If it does, can you maintain the space while simultaneously strongly straightening the legs by pushing down into the floor with the entire foot and gently lengthening up the spine toward the crown of your head?

Even if you’re not able to get to the center line, you’re moving in that direction while learning some valuable feedback about your body: Does this exercise cause actual pain in the back or just intense sensation that resolves quickly when you release the posture?  After trying this for a few minutes against the wall, try it away from the wall. Experienced yogis will recognize this as one of the foundational standing yoga poses, Tadasana. When doing it away from the wall, use the memory of the wall contact to help you find a more upright posture on your own.

Another way to play with posture is to lay on your back with your feet pressing into a wall. This will help you create the same effort used in the legs when standing. While maintaining the pressure through the feet, notice the shape of the spine and where you make contact with the floor.  If the shoulder blades don’t rest on the floor but the upper spine does, try inhaling the arms up toward the ceiling and then overhead down to the floor (don’t insist they make it all the way to the ground). Exhale them back down to the sides of the body.  Repeat this about 6 times. Then reassess the upper back and shoulder blade position.

If the low back is flat on the floor when you begin, with no evidence of the natural lumbar arch, keep one foot pressed into the wall while exhaling and bringing the other knee into the chest and using the hands to squeeze it carefully toward the body.  Inhale the leg back to its starting position and do the same on with the other leg.  Repeat side to side 6 times. See if this liberates the lumbar spine a bit.

Armed with the information about your own body, you may begin to recognize potential posture-related cases of some of your own back pain. And hopefully, these exercises have already eased some of that sensation. It’s sometimes said that all other yoga poses grow out of Mountain Pose, so in my next post, I’ll highlight some other poses that have unique value for low-back pain. Until then, stand tall, y’all!

 

Baxter Bell, MD, teaches in the San Francisco Bay Area and internationally, and is director of the Piedmont Yoga Studio's teacher-training program in Oakland, California. He is a contributing writer for Yoga Journal magazine and for the International Journal of Yoga Therapy, and created Yoga Journal’s Yoga for Stress DVD. Follow him on his other blog, Yoga for Healthy Aging or his website bellyoga.info

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