Injuries and Ailments - Advice to Yoga Teachers. Robert Brace - Yoga Academy

Transcription

1 Injuries and Ailments - Advice to Yoga Teachers Robert Brace - Yoga Academy

2 Acknowledgements Firstly I would like to thank my Anatomy teachers: Gary Carter, Julie Gudmestad, Simon Low & John Cain. Also all of the students that have come to my classes with a range of ailments or issues that forced me to research them so that I could better understand their condition. My teachers too numerous to mention, but Esther, Simon, Godfri, Gary, Julie, John and Andrea all had a major part to play and then of course Pam for starting me on this journey and supporting me on the way. Thank you. Personal research project, commercial use prohibited Copyright Robert Brace 2009

3 Contents Introduction... 1 Achilles tendon injury... 2 Angina... 2 Ankylosing spondylitis... 3 Atherosclerosis... 4 Arthritis... 5 Asthma Bursitis... 6 Frozen Shoulder... 6 Glaucoma... 7 Herniated Disks... 7 Heart Valve Replacement... 7 Hiatus Hernia... 8 Hip replacement... 8 Hypertension Hypotension... 9 Knee Injuries...10 Multiple Sclerosis...12 Osteoarthritis...12 Plantar Fascitis...13 Pregnancy...14 Prolapsed Disc...15 Repetitive Strain Injury...16 Rheumatoid Arthritis...17 Rotator cuff injury...17 Sciatica...18 Scoliosis...19 Slipped Disc...20 Stroke Tennis Elbow...21 Varicose Veins...21

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5 Injuries and Ailments - Advice to Yoga Teachers Introduction You know how it goes, you are about to start a class and you ask about Injuries and Ailments as you do every week. You spot a new student with her hand up and you expect the usual, low back or knee pain and then she whispers in your ear I have Ankylosing Spondylitis... What do you do in this situation? Most Yoga teachers are not doctors, but we are asked advice on a range of medical conditions and we should have some knowledge of the most common ones so we are aware of what the condition is, the affect it may have on the individual, what Yoga postures are contraindicated and what if any may be beneficial. You may get students with conditions you haven t heard of and in these situations the student usually knows about the condition and what they are capable of. If you are in any doubt you should not teach the student until after you and they have sought the advice of a medical expert or doctor. This guide will list a range of conditions (many of which I have experienced in my first year of teaching), explain what they are and discuss the merits of Yoga for each condition and list poses that may be contraindicated and in some cases Asana that may help conditions. However you should always work with the student and make your own judgements. You are advised to seek medical advice and treat this document as a guide because as it says above, most Yoga teachers are not doctors and this includes me. Page 1

6 Achilles tendon injury The Achilles tendon is located in the back of the lower leg, and attaches the plantar flexor muscle group (calf muscles) to the calcaneus (heel bone). The most common Achilles tendon injury is tendonitis caused by overuse most often by runners (see Repetitive Strain Injury). It is possible to tear or rupture the Achilles Tendon and this will require surgery in order to repair the injury. After the surgery has healed the patient will need to strengthen the leg muscles, especially the Gastrocnemius and Soleus muscles that attach to the Achilles tendon. Figure showing inflamed Achilles Tendon Source: New York Times An Achilles tendon injury is a repetitive strain injury and should be treated with respect. The patient will most likely have been told to rest the injury to allow it to heal before rehabilitation can start. Students can continue to practice upper body exercises (Sitting in a chair for example) and Pranayama while the injury heals. No Asana should be performed that stresses the Achilles tendon until they have been given the all clear to start rehabilitation. Gentle toe raises and balances such as Vrksasana may be beneficial as will be other standing postures such as Tadasana. Ardo Mukha Svanasana should be performed with caution keeping the knees bent and the heels raised. Remember Ahimsa and advise students to be patient. Angina Angina is chest pain or discomfort that occurs when an area of the heart muscle doesn t get enough oxygen-rich blood. Just like any other muscle in the body, the heart needs oxygen and nutrients to enable it to keep tirelessly beating. An episode of angina typically starts with chest pain or tightness in the chest when doing some sort of physical exercise. It may feel like a heavy weight or a tightening across the upper chest. Angina pain is likely to occur when extra demands are placed on the heart such as physical activity, walking, climbing the stairs, anger or stressful situations. Figure showing narrowed artery causing Angina Pain Source: New York Times Angina indicates an underlying heart or circulatory problem such as coronary artery disease (See Atherosclerosis). As well healthy living giving up smoking, reducing salt and a low fat diet, sufferers are recommended to take moderate regular aerobic exercise such as brisk walking, cycling or swimming and to reduce stress wherever possible. Individuals should seek advice from their doctor on how much exercise they should or can do. Page 2

7 Yoga can be an excellent method of both helping the underlying problem and helping to relax and deal with stress. Asana should be mild and any inverted postures or breath retention should be avoided. Raising the arms overhead may be difficult for some students, Breathing and Pranayama are specific areas to focus on. See Atherosclerosis for additional yoga information. Ankylosing spondylitis Ankylosing spondylitis is a form of arthritis that affects the lower spine and sacroilliac joints. It occasionally affects other parts of the back, other joints and other parts of the body. It usually starts as lower back pain in individuals between the ages of 15 and 35, but can occur in children and older people. The back pain is caused by the ligaments of the affected joints or lower spine becoming inflamed at the points where they attach to the bone, this inflammation triggers bone making ( ) within the ligament and in the case of the lumbar spine, these bony growths form bridges between the vertebrae and over time fuse with the vertebrae. This disease also affects the Sacroiliac joints which may ultimately fuse the Sacrum to Ilium bones of the pelvis. Where the spine hasn t already fused a daily routine that moves the spine through its full range of movements is encouraged as this may prevent or delay fusing. Yoga may be an ideal way of keeping the spine mobile, offsetting the onset of fusing and keeping the posture correct. Even where there has been some fusing of Vertebrae, the National Ankylosing Spondylitis Society recommends Dwi Pada Pitham, Chakravakasna, Tadasana and stretching overhead, Hamstring stretches such as Supta Padangusthasana with a strap, Lateral side stretches, superman stretch, spinal rotation and hip flexor stretches. Figure showing effects of Ankylosing Spondylitis Source: healthlibrary.epnet.com Page 3

8 Atherosclerosis Atherosclerosis is sometimes referred to as hardening or furring of the arteries and is a condition in which fatty deposits or plaque builds up on the insides of the arteries. Arteries are blood vessels that carry oxygen-rich blood to the heart the legs, the head and other parts of the body. Atherosclerosis causes the wall of the artery to become damaged allowing cholesterol to penetrate into the artery wall. The body tries to defend against these invasions and a small fatty cell develops. Over time these can increase and join together impeding blood flow. The artery tries to adapt and expand to keep the blood flowing, but eventually the plaque hardens through calcification and the blood flow becomes constricted. Clots may develop leading to stroke and heart attack. If the arteries of the heart are affected, constricted blood flow may cause Angina. Figure showing Build up of Plaque on artery wall Source: A surgical procedure called Angioplasty is often prescribed for Atherosclerosis whereby a miniature balloon is threaded through a blood vessel and guided to where the plaque is located. The balloon is then inflated to open the artery, held in place for a few minutes and then deflated and withdrawn. Occasionally a small wire mesh tube (called a stent) is placed around the balloon and left in situ as the balloon is deflated and withdrawn. If the artery is damaged or cannot be cleared a Coronary Artery Bypass Graft (CABG) may be required. This is where an artery from the legs or chest is used to bypass the blockage. Figure showing Stent inserted into artery Source: Page 4

9 Any Asana that puts strain on the heart should be avoided; these may include but are not limited to Navasana, Virabahdrasana (all), Ardo Mukha Svanasana, Urdhva Dhanurasana and most standing postures. Inversions are not allowed and raising the arms above the head is also not recommended. Students must be taught not to hold their breath when practising, many beginners will inhale; hold their breath and then move. This practice is particularly dangerous for students with heart problems as it raises blood pressure. Each student must be individually assessed, but in general students with heart conditions may be better served and be able to practice more safely by limiting their practice to Pranayama and Yoga practised when sitting in a chair. Yoga in combination with a healthy lifestyle and moderate aerobic exercise has been shown to reverse the effects of atherosclerosis 1. Arthritis Arthritis is a degenerative disease that affects the joints and the joint spaces. Two primary forms are usually discussed and are detailed later in this document See Osteoarthritis and Rheumatoid Arthritis, See also Ankylosing spondylitis. Asthma An Asthma attack is typified by wheezing, coughing and shortness of breath it is a serious condition and is usually triggered by an allergy or external irritant such cat or dog hair, pollen, dust, tobacco smoke, chemicals or other irritants specific to the sufferer. Stress can also be a trigger. The immune system reacts to the inhaled substance by producing histamine which causes the airways to contract and become inflamed. Yoga is recommended for Asthma sufferers. Generally there are no contra indicated postures though asthmatics are cautioned to practice Asana within students own limits as exercise can trigger an Asthma attack. Take adequate rest between Asana and encourage diaphragmatic breathing. Many Asthma sufferers have disturbed breathing patterns and breath faster than normal. Clearly Pranayama should be a key practice, but with a focus on restoring a normal breathing pattern. Barbara Benagh 2 writing in the Yoga Journal and a sufferer herself recommends a number of exercises, such as softening the effort used to Figure showing normal airway and airway inflamed by Asthma attack Source: Page 5

10 inhale and to decrease the length of the inhalation until it is shorter than the exhalation by as much as half. At first students may feel an urgent desire to breathe in more. Instead, they should understand that overbreathing is a habit that perpetuates their asthma. To help identify the basic relaxed breathing rate, begin by counting the length of the exhalation, the pause afterward, and the following inhalation. After several minutes, start to modify the breath rhythm to emphasize the exhalation. Use the baseline length of the exhalation as the gauge for any modifications: In other words, don t struggle to lengthen the exhalation; instead, shorten the inhalation. With practice, this will become easier. In the meantime, they should take several baseline breaths between cycles if they feel anxious or strained. Bursitis See Repetitive Strain Injury. Frozen Shoulder Frozen Shoulder is an extremely painful and disabling condition of the shoulder where almost all external rotation and forward elevation of the arm are lost. Technically Frozen Shoulder is referred to as Adhesive Capsulitis and it may start as an inflammation of the tendons or joint capsule (Rotator Cuff muscles and attachments) which then leads to the formation of scar tissue and limits flexion, abduction and rotation. It normally goes through three stages, extreme pain on movement, a frozen stage where pain may diminish and a stage where the shoulder starts to free up leading to almost normal movement. Time scales can be around 2 years from start to finish. Clearly the student will be in pain and pushing them into a range of motion that increases the pain will simply cause the muscles to lock to protect the joint. If the student can come to an all fours position, they may be able to raise one arm at time even if only a little on the affected side. An alternative is to stand against a wall with the palms on the wall and the elbows bent then inhale come up onto the toes and arch the body back slightly. Page 6 Downward facing dog against a wall may be an option for some, try to find some poses that will exercise the upper back and start to open up the shoulder, Supta Hastasana may help some students, lying on the floor arms at their side and then inhaling the arms to a vertical position, over time they may be able to bring the arm on the affected side further behind them. Remind them to breath into the pose and not hold their breath. Care and patience are required and overtime Yoga can help them to restore a full range of motion. See also by Julie Gudmestad.

11 Glaucoma Glaucoma is the name for a group of eye conditions in which the optic nerve is damaged at the point where it leaves the eye. This nerve carries information from the light sensitive layer, the retina, to the brain where it is perceived as a picture. The eye needs a certain amount of pressure to keep the eyeball in shape so that it can work properly. In some people, the nerve damage is caused by raised eye pressure. Others may have an eye pressure within normal limits but damage occurs because there is a weakness in the optic nerve. In most cases, both factors of high pressure and weakness in the optic nerve are involved, but to a varying extent. Eye pressure is largely independent of blood pressure. Any activity that increases the pressure in the eye should naturally be avoided. Therefore in Yoga practice, inversions are contra indicated. Even poses such as legs up the wall may increase pressure in the eye for students with Glaucoma and cause further damage to the optic nerve. Herniated Disks See Prolapsed disc. Heart Valve Replacement Heart Valve Replacement There may be a number of reasons that a heart valve is replaced, it may be through a congenital abnormality of the heart, or through age and ill health. There are four valves in the heart as shown in the diagram to the right. It is often possible to replace a valve without invasive surgery and using a catheter similar to the procedure used to place a stent. If the heart valve has been replaced through a congenital abnormality and the student is fit and well, medical advice is usually to lead as normal life as possible avoiding extreme sports such as Squash power sports (weight lifting, power training with heavy weights), badminton at a competitive level, wind-surfing and football. The student will have been advised what they can and cannot do and if their doctor has recommended them to pursue activity, then Yoga is an ideal form of exercise and stress management system for them. Figure showing valves of the heart Source: Page 7

12 If the heart valve has been replaced because of heart disease, follow the advice given for Atherosclerosis. Ensure that the students does not hold their breath when entering postures and assess each student on their merit and after they have received advice from their doctor. Ashtanga and Bikram Yoga should be avoided... Hiatus Hernia Hiatus Hernia is where part of the stomach protrudes through the diaphragm into the thorax, the symptoms are usually acid reflux, heartburn and regurgitation. Sometimes Hiatus Hernia can be brought on by stress and therefore Yoga can help in this case. Students should avoid eating before class. In severe cases inversions should be avoided and it may be necessary to elevate the head on prone postures. Hip replacement Hip replacement involves replacing the head of the thighbone (Femur) and placing an insert in the hip socket (Acetabulum). Hip replacement is a serious operation that is required when the hip joint deteriorates or is damaged. Usually a form of arthritis causes damage to the surface of the joint leading to bone on bone contact, extreme pain and immobilisation. There are a number of different types of hip replacement, some involve simply resurfacing the head of the femur and others completely replace the femur head. Page 8 Figure showing complete Hip replacement Source: Wikipedia Once the hip joint has been opened and the joint replaced, the ligaments that previously held the joint together will have been removed and the patient will rely on the muscles of the hip joint to retain the artificial femur head in the new hip socket. There is a danger of the joint becoming displaced and Yoga teachers should be aware that a variety of postures are contraindicated and extreme hip movement should be avoided. For example Eka Pada Rajakapotasana (Pigeon), deep forward bends Partial Hip replacement Source: Wikipedia

13 and lying twists. Hip dislocation is usually accompanied by a pop or noise, and by pain the groin and/ or buttocks. The affected leg will feel and look either much shorter or occasionally much longer. The foot may be rotated either outward or inward. Patients are often unable to bear weight or walk on the affected hip. A hip dislocation is not life threatening but should be treated promptly. Hypertension Hypertension is usually referred to as high blood pressure. Our hearts pump blood through the many arteries and veins in the body and blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps. Blood pressure is measured as two distinct readings, the pressure in the arteries when the heart compresses (Systolic) and the pressure in the arteries when the heart is relaxed (Diastolic). 120/80 is regarded as normal blood pressure and represents a Systolic of 120 and a diastolic of 80. High blood pressure is usually defined as a Systolic pressure of over 160 and/or a diastolic over 100. Blood pressure can be increased by a number of factors, the force at which the heart pumps and the elasticity of the arteries or how relaxed they are. Several conditions can reduce the elasticity of the arteries, blockages such as Atherosclerosis, stress causing the arteries to constrict, age in reducing the elasticity of the arteries and a variety of hereditary factors. Reducing salt intake, alcohol consumption, stress levels and exercising more (under medical guidance) may help to reduce blood pressure. Yoga and Pranayama may therefore be a valuable tool in reducing a person s stress levels and providing them with a means by which they can relax. Inverted postures are to be avoided as is raising the arms overhead. In a study of men and women with normal blood pressure, cranial blood pressure recorded when performing a headstand averaged 150/110 mmhg (Gilmore 2002). See atherosclerosis for additional information Nucleus Medical Art, Inc. Hypotension Hypotension is commonly referred to as low blood pressure. Hypotension is blood pressure that s lower than 90/60. The body is very sensitive to changes in blood pressure. Special cells in the arteries sense if the blood pressure begins to rise or fall. When this happens, the cells trigger your body to try to bring blood pressure back to normal. Page 9

14 Page 10 Diagram showing construction of knee joint Source: For example, if you stand up quickly, your blood pressure may drop. The cells will sense the drop and will quickly take action to make sure that blood continues to flow to your brain, kidneys, and other important organs. Most forms of hypotension happen because the body can t bring blood pressure back to normal or can t do it fast enough and the body s natural reaction is to get the head at the same level as the heart hence fainting brings the body horizontal. Ensure the students take breaks between standing sequences. Standing too long may cause blood pressure to drop, resulting in dizziness. Also be careful coming to standing from Uttanasana and other forward bends, it may be better to roll the spine up and keep the hands at the side rather than sweeping the arms overhead. Knee Injuries There are many different types of knee problems or injury. The knee is an extremely fragile area of the body and can be easily damaged. The knee is primarily a hinge joint although there is a small degree of rotation possible when the leg is straight. Movements and postures that stress this joint can cause problems to the ligaments that hold the knee together and the cartilage that cushions the femur from tibia. Deep inside the knee are the cruciate ligaments that allow the knee to bend yet prevent the Femur from sliding off the Tibia. These can be damaged or torn by sudden twisting movements and are difficult to heal because of limited blood flow to the ligaments. The medial and lateral menisci are fibrous pads of cartilage that cushion and facilitate movement of the Femur over the Tibia. Flexing the knee sideways can cause damage to these pads as can a variety of sports activities such as running and football. Students with stiff hips who force their legs into Padmasana (Lotus Pose) can easily cause permanent damage to the menisci and this damage may never heal. There are also a number of alignment issues that can cause uneven wear and damage over a long period of time such as running or walking. In order to protect your students knees there are several things you should be aware of. In kneeling postures some students will have pain from kneeling and an extra mat or blanket may be used to make them feel more comfortable. Warm up with postures that work to loosen the hips, Hip Circles and Baddha Konasana for example. Use blocks where possible. Try sitting on blocks to get the hips above the knees (which also helps

15 lumbar spine alignment), use blocks under the buttocks in Virasana, use a rolled up blanket or towel in Balasana behind the knees and use straps in Supta Padangusthasana. Most important is to start to bring the students an awareness of correct alignment in standing postures such as Tadasana, concentrate on the four corners of the feet, an even weight between the inside and outside edges of the feet and the Achilles Tendon visibly straight between the heel and the calf muscle. If you look at the students heels in Tadasana or Ardo Mukha Svanasana you can see if they have more weight on the inside or the outside of the feet. This is key to alignment in the knees and maintaining strength in the ligaments. Some students have a habit of hyper extending their knees and locking them with what can be seen as a slight reverse bend to the knee, this is usually most obvious in Trikonasana and Tadasana although some students show this tendency in straight leg seated postures such as Dandasana and Paschimotanasana. Hyper extending tends to put too much strain on the cruciate ligaments. Students with this tendency (which I suffered from when I started Yoga) should concentrate on keeping a slight bend in the knee, lifting the kneecaps and activating the thigh muscles. In seated postures a rolled up mat can be used under the knees. I prefer my students to practise Utkatasana and Uttanasana from Tadasana with knees hip width apart; this provides better alignment and integrity for the knees - The knee is aligned centrally between the hip joint and the ankle joint. MRI scan of the knee showing Cruciate Ligaments Source: Wikipedia In Virabahdrasana II and Parsvakonasana ensure that the knee joint is no further forward than the ankle joint and ensure that the hip knee and second toe are aligned on the front leg. Extending the knee past the ankle puts way too much stress on the cruciate ligaments. Also ensure that the students maintain an awareness of the back foot, outside edge pressing down, big toe pressing down and the back leg straight, lift from the arch of the foot. Strengthen the muscles that support the knee by using balancing postures. Balancing poses, especially those that require moving through a bent knee such as Garudasana are helpful. Page 11

16 Multiple Sclerosis Multiple sclerosis (also known as MS) is an autoimmune condition in which the body s immune system attacks the central nervous system. MS affects the ability of nerve cells in the brain and spinal cord to communicate with each other. Nerve cells communicate by sending electrical signals down long fibres called axons, which are wrapped in an insulating substance called myelin. With MS, the body s own immune systems attack and damage the myelin. When myelin is lost, the axons can no longer effectively conduct signals and this can affect many of the body s in many ways including movement, mobility and balance, pain, muscle spasms and muscle tightness. Image showing Myelin Sheath covering an axon. Source: There is no cure for MS, it is a progressive disease, but research is continuing into the condition and its causes. There are many treatments for MS which aim to improve the symptoms, make them easier to live with and improve the patient s lives. Treatments include medication and physiotherapy. Yoga can play an important role in the student s well being, but you should have an awareness of what the student is capable of when working with them. They may need the wall for balance and may not be able to coordinate a sequence easily. Patience and care are required and in advanced cases 1:1 s might be more appropriate to avoid disrupting the rest of the class. Pranayama is a good option and some Asana may be performed on a chair, Uttanasana for example. Ardo Mukha Svanasana can be performed against a wall and Vrksasana may be performed only lifting the leg as far as the ankle and using a wall for stability. There are multiple options, but the student s safety and comfort should be paramount. Page 12 Image showing Osteoarthritis damage to the knee Source: Osteoarthritis Osteoarthritis is a degenerative disease that affects the joints by causing degradation of the articular cartilage and the subchondral bone surfaces of the joint. Over time the cartilage can become completely worn away leading to bone to bone contact within the joint and extreme pain. Osteoarthritis has a number of causes including hereditary, mechanical and metabolic processes that may lead to the loss of cartilage (which the body cannot replace) and ultimately bone to bone contact which can the accelerate the condition. Joint replacements such as artificial, knee and shoulder are usually the only option for many sufferers. Yoga should not aggravate the existing condition and you may need to focus on other areas of the body or just on Pranayama as focussing on the breath may bring relief to many sufferers. Students should dis-

17 cuss their desire to start yoga with their doctor and ask about any restrictions. Yoga has been shown to bring help to many by keeping mobility and strengthening other parts of the limbs to help compensate for loss of movement and strength elsewhere. A pilot study conducted by the University Of Pennsylvania School Of Medicine used a modified form of Iyengar yoga for people with osteoarthritis of the knee. After 8-weeks of once a week 90-minute beginner classes, there was a statistically significant reduction in pain, Increased physical function, and enhanced mood. Plantar Fascitis The plantar fascia is a strong band of tissue (similar to a ligament) that stretches from the heel to the middle bones of the foot. It supports the arch of the foot. Small injuries to the plantar fascia can cause inflammation and these are usually near to where it attaches to the heel bone. The condition involves heel pain that generally occurs after, rather than during exercise. Plantar fascitis is most commonly caused by either hyperpronation (flat feet), hypersupination (high arches), or excess body weight increasing the load on the plantar fascia. Treatment is usually nonsurgical, with the RICE protocol (Rest, Ice, Compress, Elevate), anti-inflammatory medication, gentle stretching exercises, and orthotics. In severe cases surgery may be required. The plantar fascia connects to the heel of the foot (calcanus) and via the periosteum of the bone connects to the Achilles tendon. Then through the Gastrocnemius and Soleus muscles to the hamstrings and on through the pelvis and muscles of the back to the brow of the head. Relieving tension through this line of muscle, tendons and ligaments can help. Ardo Mukha Svanasana, Utkatasana and Garudasana can help relieve the fascia of the back, the calf muscles and hamstrings which in turn may help relieve tension in the plantar fascia. Rolling a tennis or golf ball for a few minutes around the sole of the foot may also help relieve tension in this area by relieving and gently stretching the plantar fascia. Numerous fascial paths exist in the body and the above mentioned poses may provide a loosening of the line of fascia that begins at the bottom of the foot and works its way up through the posterior aspect of the body. Addressing the muscular weaknesses in the body is also essential for developing a plan to address the tight areas of the body. Most often, weak links cause tightness; therefore, without targeting the origin Page 13

18 of the tightness, no amount of stretching will correct the problem. The root of the problem must be discovered for an optimal plan to be derived for an individual. See Anatomy Trains by Tom Myers Pregnancy General Precautions from Rachel Barrance of the British Wheel of Yoga 3 : Lying on the back during pregnancy pushes the weight of the uterus and baby downwards, which compresses the vena cava, the main vein which brings blood from the organs back to the heart. This compression and restricted blood flow can be felt in the mother by breathlessness, dizziness or tingly legs. The blood supply to the placenta is also affected. Lying with the legs bent relieves the pressure, as does lying with the legs up the wall. A wedge can also be placed under the right hip to further free up the vena cava return. After weeks pregnancy, lying on the left side of the body is said to encourage Optimal Foetal Positioning, and from this point, lying on the right side or on the back should be avoided for any more than a few minutes at a time. Pregnant women should spend little time on the back, even with knees bent, and should be told to roll over off their back and onto their left side every few minutes, however early they are in their pregnancy, to get them into good habits. When coming out of Savasana or other prone positions, pregnant women should roll onto their left sides and not their right. Relaxation and sleeping should always be on the left side (cushion under the head, another under the upper/right bent knee), particularly from 30 weeks onwards, as Optimal Foetal Positioning should be heartily encouraged. Page 14 Other precautions and prohibitions to be aware of in pregnancy are: Do not retain the breath at any time. Focus on the exhalation and breathe slowly. Do not practice anything which is uncomfortable or does not feel right. Avoid standing for long periods of time or hold standing postures for too long - practice dynamic postures instead of static. Shorten the stance in standing postures. Yoga practice should no longer be strenuous/raise the heart beat. Do not overstretch into a posture; ligaments are naturally softer during pregnancy believed to be 3

19 due to the release of the hormone Relaxin. There should be no pressure felt on the abdomen at any time during the class. Do not lie on the stomach. Be aware that pregnant women can feel emotionally more vulnerable and therefore be cautious with guided visualisations or mental images in relaxation states. Finally, remember the student is ultimately responsible for the care of her own body and baby, however a pregnant women in a general yoga class is not as ideal as a yoga for pregnancy class Prolapsed Disc The spine is made up of a number of vertebrae separated and cushioned by discs that have a fibrous outer and a fluid core. When an individual is suffering from a prolapsed disc (commonly referred to as a slipped disc), the soft gel like core breaks through the tough fibrous outer layer creating a bulge that may press on a nerve or the spinal column causing severe and debilitating pain. If the fluid core causes the disc to rupture, surgery may be required. Generally the disc simply herniates creating a bulge that impinges on a nerve. In the past, advice had been to rest until the pain eases. It is now known that this was wrong. Sufferers are likely to recover more quickly and are less likely to develop chronic (persistent) back pain if they keep active when they have back pain rather than rest. Clearly some Yoga postures are not going to be possible and some need to be performed with caution. In all cases a program should be tailored to an individual s needs as there are no general postures for prolapsed discs. Modifications should be considered using blankets, blocks, bolsters, straps, and other props to put gentle traction on the spine. Image showing prolapsed and herniated disc Source: Deep forward bends such as Uttanasana and intense back bends such as Dhanurasana are out of the question for most students as is bending forward past 90 degrees with straight knees so avoid all seated forward bends and avoid rounding the back. If a pose causes any pain, tingling, or numbness, stop immediately. Asana such as low Bhujungasana, Savasana with legs elevated, knees bent, calves supported on chair seat, Tadasana, Bharadvajasana seated in a chair, Ardha Urdhva Mukha Svanasana (Half Upward- Facing Dog Pose) with hands on back of chair or against a wall, not on floor, Balasana with trunk supported on a bolster or three long folded blankets and Supta Padangusthasana with belt around foot and bent knees at first. Image showing progression of herniated disc Source: Page 15

20 Image showing carpal Tunnel Source: Repetitive Strain Injury Repetitive Strain Injury (RSI) is a term used to describe a range of injuries to tendons, muscles and ligaments believed to be caused by repetitive overuse. Upper Limb Disorder is another term used to describe RSI as it is usually the upper half of the body that is affected. Some typical RSI injuries include: Bursitis - inflammation and swelling of the fluid-filled sac near a joint at the knee, elbow or shoulder (Housemaids knee for example) Carpal tunnel syndrome - pressure on the median nerve passing through the wrist (Classic overuse/misuse of mouse/keyboard), Anjali Mudra has been shown to help this condition Dupuytren s contracture - a thickening of deep tissue that passes from the palm of the hand into the fingers, sufferers have an increased likelihood of Frozen Shoulder Epicondylitis - inflammation of an area where bone and tendon join, an example of epicondylitis is tennis elbow Ganglion - a cyst in a tendon sheath, usually occurring on the wrist Rotator cuff syndrome - inflammation of muscles and tendons in the shoulder. Tendonitis - inflammation of a tendon Tenosynovitis - inflammation of the inner lining of the tendon sheath that houses the tendons that control the fingers and thumbs Trigger finger - inflammation of the tendon sheaths of fingers or thumb accompanied by swelling of the tendon Plantar Fascitis - small injuries to the plantar fascia can cause inflammation and these are usually near to where it attaches to the heel bone Lists of postures and one-size-fits-all approaches are not useful for a category as broad as RSI as practices that help one condition may worsen another. In addition, as people heal, a pose that may be contraindicated one day might be possible a few months later. It is essential not to aggravate the condition, so alternative postures or props should be used to alleviate pain such as Ardo Mukha Svanasana using balled fists or support bars to avoid bending the wrist in carpal tunnel syndrome. Because of the self-perpetuating nature of soft-tissue injuries, it s extremely easy to re-injure with RSI, and relapses can be worse than the initial injury. Sometimes students will disregard warnings to avoid strain, so watch facial expressions, quality of movement and breathing, and stop them immediately if there is any sign of struggle or strain. Ahimsa (non-harming) should be emphasized. Page 16

21 Rheumatoid Arthritis Rheumatoid arthritis is believed to be an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the Synovial tissue around the joints ultimately leading to the destruction of the articular cartilage. This then causes the fibrous connective tissues of the joint to become inflamed and ossify fusing the joint together. Simon Borg-Olivier in his book on Applied Anatomy and Physiology of Yoga cites a number of articles and research that show an Alkaline diet (largely Vegan/Vegetarian) can help the symptoms of Arthritis and Jason Theodosakis, M.D. Author of The Arthritis Cure (St. Martin s, 1997) recommends a diet high in antioxidants to reduce the free radicals in the bloodstream which he believes are a prime cause of rheumatoid arthritis. Yoga should not aggravate the existing condition, an inflamed joint should never be pushed, stretched into pain, or worked vigorously, because the risk of increasing or prolonging the inflammation is great. You may need to focus on other areas of the body or just on Pranayama as focussing on the breath may bring relief to many sufferers. Students should discuss their desire to start yoga with their doctor and ask about any restrictions. Yoga has been shown to bring help to many by keeping mobility and strengthening other parts of the limbs to help compensate for loss of movement and strength elsewhere. Yoga is recommended for rheumatoid arthritis by a number of leading institutions including the John Hopkins Arthritis Centre. 4 Image showing Normal and Arthritic Joints Source: Rotator cuff injury The rotator cuff (rotor cuff ) is a term used to describe the group of muscles and tendons that act to stabilize the shoulder. Along with the Teres Major and the deltoid, the four muscles of the rotator cuff (Infraspinatus, Supraspinatus, Teres Minor and the Subscapularis) make up the six scapulohumeral muscles that connect to the humerus and scapula and act on the glenohumeral joint. Rotator cuff injury is a general term used to describe a number of injuries or damage to the shoulder joint complex. Inflammation of the rotator cuff tendons is one of the most common conditions and is also described under Repetitive Strain Injury. Symptoms of a rotator cuff injury may include: Pain and tenderness over the shoulder, particularly when the arm is abducted, stretched behind the body or used to lift or pull a heavy weight Pain at night, particularly when sleeping on the affected side 4 Image showing torn Supraspinatus muscle Source: Page 17

22 Page 18 Image showing location of sciatic nerve Source: A feeling of weakness in the shoulder A limited range of movement (but see Frozen Shoulder) Depending on the type of injury, the pain may come on gradually (common in tendonitis) or there may be a sudden twinge of pain (common if it s a tear) Patients are initially advised to rest the affected shoulder, avoiding any movements which cause the shoulder to be painful. Then to begin gentle movements as soon as possible in order to prevent stiffness in the shoulder. Students who come to Yoga to rehabilitate the Rotator Cuff muscles should start with light exercises to build strength. All fours to lifting opposite arm and legs dynamically - Stretching left arm out horizontal and right leg, then back to all fours and the opposite side. Chakravakasna and Ashtanga Mudra are also a good start and from here to gradually work towards stronger poses such as Ardo Mukha Svanasana and Plank, although plank may be beyond many people who have not had a rotator cuff injury. It is important in a general Yoga practice to do Asana that keep the rotator cuff muscles strong and supple, Activating the Infraspinatus and Teres Minor for example in Ardo Mukha Svanasana by externally rotating the elbow creases and pressing down on the inner wrists to spiral the arms. It is also important to work on opening the chest. Standing upright with the shoulder blades sliding down the back is a good practice to get into as it prevents the shoulder blades tipping forward preventing the head of the humerus pinching against the acromion and reducing strain on the rotator cuff. See also yogajournal.com/lifestyle/1102 by Julie Gudmestad. Sciatica The sciatic nerve is one of the largest and longest nerves in the body, it emerges from the sacrum passes over the Piriformis muscles (in 15% of the population is passes through the piriformis) in the buttocks and down both legs to the feet. Any irritation of this nerve can cause mild or excruciating pain that starts in the lower back and runs down the legs. Herniated disks in the Lumbar area or tight muscles such as the Piriformis can cause irritation. Yoga has been shown to help many sufferers of sciatica where the symptoms are due to tight muscles. Postures such as Pretzel or Eka Pada Rajakapotasana (Pigeon) where the Piriformis can be isolated and stretched have been shown to help some sufferers.

23 Asana to avoid: Forward bends such as Utanasana, Janu Sirshasana and Paschimotanasana can aggravate the pain by stretching the muscles at the back of the leg putting additional pressure on the sciatic nerve; also forward bends tend to stretch the sciatic nerve. Over time Forward bends may become easier and more beneficial. Paschimotanasana can be practised with the knees raised using a bolster or rolled up blankets. Twists such as Jathara Parivrtti may also cause problems by tightening the Piriformis and compressing the nerve. Asana that may help: Most standing poses, Tadasana etc, Supta Padangusthasana can provide gentle stretching of the muscles at the back of the leg especially if performed with a strap, Ardo Mukha Svanasana working the head of the femur into the hip socket using the Quadriceps and Hamstrings, Parsvakonasana in stretching from the outside of the backfoot to the fingertips, Pretzel or Eka Pada Rajakapotasana (Pigeon) where the Pirifomis can be isolated and stretched and Savasana for total relaxation. Scoliosis In Most people the spine has a distinct S shape when viewed from the side, The Lordotic curve of the Lumbar and Cervical Spine and the Kyphotic curve of the thoracic spine make up this natural curve. When viewed from the back the spine is usually straight or very nearly so. With Scoliosis the spine also curves from side to side, it has lateral deviation. Most of us have some form of imbalance caused by the muscles on one side of the spine being stronger than the other so for example sports that emphasise one side of the body such as Archery, Tennis and Golf etc would tend to strengthen the muscles on one side of the spine. With Scoliosis however, the curve is very pronounced and in some individuals can be crippling. Sometimes surgery is performed to correct the curvature by fusing vertebrae together. Rods used to be used, but these tended to cause early onset arthritis. Braces may be used to encourage the back to straighten on its own. Braces would be used when the spine has still some growth potential. Again there is no one size fits all set of Yoga postures. Each student needs to be assessed individually. Elise Browning Miller is a yoga teacher suffering from Scoliosis and has an article on the Yoga Journal Web site that describes Yoga Asana she has found most effective. She recommends focussing on six major areas while teaching students with scoliosis, they are very important in creating proper alignment, decreasing pain, and minimizing further curvature of the spine. 1. Feet and legs. When standing and walking, it is very important that students place equal weight on both feet and become aware of any imbalances. Strengthening the legs creates a solid foundation Image showing spine with severe scoliosis Source: Page 19

24 from which the spine can stretch and become freer, and it enables the legs, rather than the spine, to carry the weight of the body Spine. Since this is where the scoliosis is located, it is important to help students focus on lengthening the spine, which tends to reduce the lateral curvature. Psoas (Major and Minor). These two muscles (a pair on each side of the body) are the principal flexors of the thigh. They arise from the iliacus muscle and along the vertebral column and join to insert on the lesser trochanter of the femur. Together with the iliacus, they form a structural and functional unit called the iliopsoas. Besides flexing the thigh, the iliopsoas is an important postural muscle. During sitting it balances the torso; in standing it counteracts the tendency of the torso to fall behind the line of gravity, which passes just in back of the hip joints. Keeping this muscle well toned aligns the lower limbs with the torso and frees the spine. Scapula. To prevent the upper back from rounding (a common problem in people with scoliosis), it is important that students drop the shoulder blades down the back and draw them in toward the front of the body. To facilitate this movement, they must develop increased flexibility of the muscles surrounding the shoulder blades. Abdominal Muscles. Students must work to strengthen their abdominal muscles. If the abdominals are weak, the back muscles overwork and therefore tighten. In extreme cases, this may cause lordosis or an extreme curve of the lower back particularly on the concave side of the lower back. Breath. Awareness of the breath is perhaps the most important thing to teach students to cultivate while doing the yoga poses. Usually very little air enters the lung on the concave side of the spine. Sending the breath into the collapsed rib cage on this side can actually stretch the intercostal muscles and create more lung capacity. This creates more openness and evenness on both sides of the chest, from the inside out. Page 20 Image showing how a stroke can occur during atrial fibrillation Source: Slipped Disc See Prolapsed Disk Stroke A stroke is what happens when the blood supply to part of the brain is cut off. Blood carries essential

25 nutrients and oxygen to the brain. When a stroke occurs brain cells become damaged or destroyed and this affects the person s abilities that the area of the brain that is damaged controls. For example, if a stroke damages the part of the brain that controls how limbs move, limb movement will be affected. In general follow the same guidelines as for Atherosclerosis, however there are different kinds of stroke. In a stroke caused by plaque build up in the carotid artery breaking free and heading to the brain, twisting the neck is to be avoided, so twists and keeping the head neutral should be practised. Some stroke patients lead a near normal life and I have one in one of my classes who is nearly as able as a stroke free student with the exception of weakness in one arm. Modifications may be appropriate such as Virabahdrasana using a chair to support the front leg or Trikonasana releasing onto blocks or a chair. As with all conditions like this ensure that the student has consulted their doctor and has the OK to come to a yoga class. Avoid Bikram, Ashtanga and power yoga. Tennis Elbow See Repetitive Strain Injury Varicose Veins Varicose Veins are caused by failure of the small one way valves that exist in the veins of the legs to keep the blood moving in one direction around the body. The lower limbs are quite a distance from the heart and to blood flowing in one direction back to the heart, the veins of the legs have tiny one way valves that let the blood flow up the leg to the heart, but prevent the blood from moving back down the leg during the diastolic phase of the heart rhythm. Once the valves have failed there is little that can be done to help. Yoga s stretching and relaxation techniques can be particularly beneficial for varicose veins. Certain positions, such as Halasana, Savasana, Viparati Karani and Half Shoulder Stand, promote circulation and the drainage of blood from the legs. Pranayama may alleviate discomfort by getting more oxygen into the bloodstream and Savasana with the legs raised over a bolster may make the student more comfortable. Image showing formation of Varicose Vein Source: Page 21

26 Bibliography Borg-Olivier Simon & Machliss Bianca. Applied Anatomy & Physiology of Yoga: Australia Yogasynergy Pty Ltd Peters David Professor, New Medicine: London Dorling Kindersley 2005 Hately Susi Aldous, Anatomy & Asana: Seattle Eastland Press 2006 Myers Thomas W. Anatomy Trains: Churchill Livingstone 2007 Hately Susi Aldous, Anatomy & Asana the Knees: Calgary Functional Synergy Press 2005 Hately Susi Aldous, Anatomy & Asana The Shoulder Girdle: Calgary Functional Synergy Press 2005 Netter Frank H, Atlas of Human Anatomy: Philadelphia Saunders Elsevier 4th Edition A. G. Mohan & Indra Mohan, Yoga Therapy: Boston Shambhala Publications 2004 A. G. Mohan & Indra Mohan, Yoga for Body, Breath and Mind: Boston Shambhala Publications 2002 Kraftsow Gary, Yoga for Wellness: New York, Penguin Compass 1999 Desikachar T.K.V, The Heart of Yoga: Developing a Personal Practice : Vermont Inner Traditions Bear and Company 1999 Iyengar B.K.S. Yoga the Path to Holistic Health : London Dorling Kindersley 2005 Desikachar T.K.V, The Viniyoga of Yoga: India Quanda Press Limited Atherosclerosis Page 22

27 Index A Acetabulum 8 Achilles tendon 11, 13 Achilles tendon injury 2 Adhesive Capsulitis 6. See Frozen Shoulder Ahimsa 16 Angina 2 Angioplasty 4 Ankylosing spondylitis 3, 5 Arthritis 5. See also Ankylosing spondylitis; See Osteoarthritis; See Rheumatoid Arthritis Asana Ardo Mukha Svanasana 2, 5, 11, 12, 16, 18, 19 Ashtanga Mudra 18 Baddha Konasana 10 Balasana 11, 15 Bharadvajasana 15 Bhujungasana 15 Dandasana 11 Dhanurasana 15 Eka Pada Rajakapotasana 18 Garudasana 13 Halasana 21 Janu Sirshasana 19 Jathara Parivrtti 19 Navasana 5 Padmasana 10 Parsvakonasana 11, 19 Paschimotanasana 11, 19 Savasana 19, 21 Supta Hastasana 6 Supta Padangusthasana 11, 15, 19 Tadasana 11 Trikonasana 11 Urdhva Dhanurasana 5 Utkatasana 11 Uttanasana 10, 19 Viparati Karani 21 Virabahdrasana 5, 11 Virasana 11 Vrksasana 12 Ashtanga 8, 21 Asthma 5 Atherosclerosis 2, 4 5 Axons 12 B Bibliography 22 Bikram 8, 21 Blood pressure 5 Bursitis 6 C Calcanus 13 Cartilage 10 Coronary Artery Bypass Graft 4 Coronary artery disease 2 Cruciate ligaments 11 D Diastolic 9 F Femur 8 Frozen Shoulder 6 G Glaucoma 7 H Heart Valve Replacement 7 Herniated Disks 7 Hiatus Hernia 8 High blood pressure 9 Hip replacement 8 Hyper extending 11 Hypertension 9 Hypotension 9 I Infraspinatus 17 Iyengar 13 K Knee Injuries 10 L Lateral menisci 10 Low blood pressure 9 M Medial menisci 10 Menisci 10 Multiple Sclerosis 12 Myelin 12 O Optic nerve 7 Optimal Foetal Positioning 14 Ossification 3 Osteoarthritis 12 P Piriformis 18 Plantar Fasciitis 13 Pranayama 2, 3, 5, 9, 12, 17, 21 Pregnancy 14 Prolapsed Disc 15. See Tennis Elbow R Relaxin 15 Repetitive Strain Injury Bursitis 6 Carpal tunnel syndrome 16 Dupuytren s contracture 16 Epicondylitis 16. See also Tennis Elbow Page 23

28 Index Ganglion 16 Plantar Fascitis 13, 16 Rotator cuff syndrome 16 Tendonitis 16 Tennis Elbow 21 Tenosynovitis 16 Trigger finger 16 Rheumatoid arthritis 17 RICE 13 Rotator cuff injury 17 S Sacrum 3 Sciatica 18 Scoliosis 19 Stent 4, 7 Subscapularis 17 Supraspinatus 17 Systolic 9 T Tennis Elbow 21 Teres Major 17 Teres Minor 17 V Varicose Veins 21 Vertebrae 3, 15, 19 Page 24

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