Preventative Strategies for Lower Back Strains in Yoga: Part One

In this post we take a look at one of the leading causes for emergency room visits from yoga—lower back strains—and examine preventative strategies that may help in reducing the risk of this injury while enhancing the benefits of Hatha yoga practice. This series begins with info on joint rhythms and how understanding them can help in preventing injury.

Also, I would like to recommend reading Dana Santas interview in Men’s Health magazine entitled “Will Yoga Really Wreck Your Body?”¹ Dana is an experienced yoga practitioner and teacher who works with elite athletes from a number of professional sports. She is a great resource for information on integrating yoga into sports training regimens. Next, please read (and circulate) Jason Amis’ counterpoint to a recent article published in the New York Times, which includes a clear and in-depth analysis of much of the data that was referenced. Extremely well done – Kudos! 

Jason provided me with the NEISS data relating to emergency rooms visits for yoga injuries in 2010 and I’ve done some preliminary analysis, which I will share with you. Data like this is extremely valuable, because it allows us to find ways to identify risks and then reflect on how to prevent them – a variation for the yoga community on the Sanskrit term “Atma Vichara,” or self inquiry. Here are my impressions: first, I was impressed by the relative safety of the practice compared to other activities. Second, it was clear to me that many of the injuries resulting in ER visits were potentially preventable. Think of it this way: there are injuries that are unpredictable, like stubbing your toe (also reported as an ER visit related to yoga), and there are those that are potentially preventable through application of common sense and knowledge of the body. Analysis of data like this provides an opportunity to identify preventable injuries and eliminate unsound practices that may have caused them in the first instance. 

For example, lower back strains were the most common single diagnosis reported in the data for ER visits relating to yoga for 2010 (from the NEISS report). In fact, back strains are also a common workplace injury and much research is focused on the prevention thereof. Nevertheless, people still often strain their back at work, especially during situations in which they forget or are unable to implement preventative measures.

There is never any reason to rush or force oneself into a yoga pose, so it is possible that many of the back strains that occurred were preventable through working with proper technique, using modified poses where indicated and not rushing. Then, the practice becomes potentially therapeutic for the lower back, as has been demonstrated, rather than injurious.

Since I suspect that a percentage of these lower back strains may have arisen during forward bending poses, let’s begin by looking at the concept of lumbar-pelvic and pelvic-femoral rhythm in the forward bend Paschimottanasana.  

Pashimottanasana illustrating lumbar-pelvic and pelvic-femoral rhythm.

Lumbar-pelvic rhythm refers to a type of joint coupling whereby tilting the pelvis in one direction produces a corresponding movement in the lumbar. Tilting the pelvis back (tucking the tailbone) produces flexion of the lumbar vertebrae. Tilting the pelvis forward produces extension. (I give a practical example of the former in a previous post on engaging the abs and gluts in Chaturanga.)

Pelvic-femoral rhythm refers to joint coupling at the hip whereby flexing the femur produces a corresponding forward tilt of the pelvis – and vice versa for extending the femur.

I access these rhythms when I work with yoga poses – especially forward bends – by gently engaging muscles that improve hip flexion and anterior tilt of the pelvis (joint coupling between the pelvis and the hip) and releasing the muscles that can limit hip flexion. In this manner, the forward bend comes more from the hip than the lumbar spine.

The hamstrings, for example, are hip extensors. They can limit hip flexion. Contracting the quadriceps contributes to releasing them through reciprocal inhibition. One head of the quadriceps, the rectus femoris, is also a synergist of hip flexion (and anterior tilt of the pelvis). Thus, engaging the quadriceps helps to produce forward bending from the hips rather than the lumbar. In general, when practicing forward bends, movement of the pelvis on the hips should be equal to or greater than movement of the lumbar spine in relation to the pelvis, otherwise flexion is concentrated in the lower back.

Pashimottanasana illustrating joint rhythm with quadriceps engaged. 

As an aside, I also use periodic gentle muscular engagement of the quads when I am practicing a longer duration relaxed forward bend that is directed towards lengthening myofascial sheaths. Periodically engaging the agonists – or yang side of a stretch – does not diminish the lengthening on the antagonist (yin) side. In fact, it can enhance it both biomechanically and physiologically. This engagement also re-establishes alignment and mental focus. The Mat Companion Series provides a step wise approach to understanding the various muscles in the poses from this perspective as well.

Now, let’s look at what happens when we eliminate engaging the quads, for example, out of fear that the rectus femoris will cause “congestion”. We lose reciprocal inhibition of the hamstrings, which remain tight through the action of the muscle spindle in a stretch. This limits hip flexion. We also lose the contribution of the rectus femoris to hip flexion and forward tilt of the pelvis. The result is that the forward bend is produced more from the lumbar than the hips, which may contribute to lower back strain. Thus, avoiding an imaginary problem potentially causes a real one. For more info on the rectus femoris not causing “congestion”, see our blog post on how misguided cautions decrease benefits and increase risks.

Pashimottanasana illustrating joint rhythm without engaging the quadriceps. Note the increased lumbar flexion.

Unsound theory is like a fly in the ointment. These things become “memes” that get circulated as if they were based on truth. And although such theories are often not based in reality, they can have manifestations in the real world, including a potentially increased incidence of back strains and other injuries. These problems then get sensationalized in the media and so on. Ironically, such media coverage can lead to well considered analysis – like Jason’s – which then helps to identify and eliminate potentially harmful disinformation and implement an affirmative strategy of prevention.

If you suffer from back pain, be sure to consult your physician to determine the cause; work under the guidance of a physician to manage your pain (see our full disclaimer here).

Great seeing you all again! Check in next week for Part Two of this series on preventative strategies for lower back strains in yoga. Also, be sure to visit us on Facebook for your free Chakra poster and e-book.

Namaste’ 

Ray and Chris

1. Greenfield, Paige. "Will Yoga Actually Wreck Your Body? | Men's Health News." Men's Health Magazine. 20 Jan. 2012. Web. 24 Jan. 2012. <http://news.menshealth.com/yoga-men-injuries/2012/01/20/>.

The Benefits of Engaging the Quads in Forward Bends (and the risks of misguided cautions)

In our last post we mentioned that true caution is based on accurate knowledge and wisdom; practicing it in yoga enhances benefits and minimizes risks. In this post, we talk about misguided caution and provide a couple of examples. This type of caution is usually based on fear: If you do “this”, a bad thing will happen. In fact, misguided cautions can enhance the risks and diminish the benefits of yoga because following them, among other things, diverts your focus from what is important. Think about it like this: You’re driving along the freeway and, for no reason, your passenger gets scared and yells, “STOP!” So you put on the brakes when you should apply the gas. The result is a pile-up. It's a type of passive aggressive way to decrease benefits and increase risks.

Two widely circulated examples of misguided caution relate to engaging the quadriceps in various yoga poses. One is that people with strong quads and misaligned kneecaps experience rapid progression of arthritis, and the second is that we should avoid contracting the rectus femoris in forward bends because it can cause “congestion”. Neither of these misconceptions has any basis in science, yet they are prevalent and have been incorporated into the curriculum of yoga, creating a conflict among teachers and practitioners. This has resulted in many teachers discouraging students from engaging these important muscles for fear of potential injury. I’ll address each of these “cautions” in turn later in the post, but in order to help resolve this conflict, let’s go over some of the basic science for the muscles and joints and then look at the benefits of engaging the quadriceps in a forward bend like Marichyasana I.

As I discuss in my books, joint stability is determined for each individual articulation by a combination of three factors: bone shape (ball and socket vs. hinge, etc.), the capsule and ligaments, and the muscles. At the joint, the bones are covered with articular cartilage. This cartilage and the ligaments surrounding the joints should be protected during a stretch. Stretching ligaments beyond about 6% of their normal length (from which they still recoil) can result in loss of their contribution to stability, especially if done on a regular basis. Unstable joints become incongruent; their surfaces do not match perfectly according to their design. When joint surfaces become incongruent, this can damage the articular cartilage and lead to arthritis. The muscular stabilizers form a type of dynamic sleeve around the joints and aid in protecting them by maintaining joint congruency. This concept is well supported, especially by experts in body weight training (a time-honored system similar to gymnastics that uses the body weight itself for conditioning, rather than external weights).

The beneficial effect of activity—which necessarily includes muscular engagement, especially the quadriceps—on joint cartilage is also supported by the peer-reviewed medical literature, including a recent review¹ of articles evaluating the effect of activity on the knee joint. The theory behind this is that cartilage responds positively to judiciously applied forces. One of the reviewed articles states:

In conclusion, we demonstrated a protective effect of past and current vigorous physical activity on knee cartilage in healthy, community-based adults with no history of knee injury or disease. ²

(click here for full text PDF)

The quadriceps stabilizing the knee joint in Marichyasana I.

Next, let’s take a look at the cascade of beneficial effects that ensues when you do engage the quadriceps of the extended knee in Marichyasana I. This includes: 1) improved joint alignment and stability at the knee; 2) release of the hamstrings through reciprocal inhibition (so that lengthening occurs in the muscle belly, rather than overstretching in the tendons); and 3) the rectus femoris synergizes the psoas in flexing the hip and tilting the pelvis forward. This aids in preventing hyperflexion of the lumbar spine in the pose through joint coupling (lumbar-pelvic rhythm). (For those who tend to hyperextend the knee, use co-contraction of the quadriceps and hamstrings to maintain alignment).

The rectus femoris synergizing anterior tilt of the pelvis.

This is only one example of one muscle benefitting a pose; obviously we don’t engage all of the muscles at once in any given pose and may even relax completely in certain restorative poses. What I recommend is incorporating periodic muscular engagement into your practice—I call this “walking around the pose”. In addition to the benefits described, practicing in this way establishes the mind-body connection and focuses attention, thus creating a meditative state within a hatha yoga practice. The Mat Companion series takes you through the muscles involved in stabilizing the joints in the asanas as well as cues for engaging them—and much more. Feel free to browse through this collection at the Bandha Yoga website.

Now, let’s look at the two examples of misguided caution that we cited earlier:

The first states that “people with strong quads and misaligned kneecaps experience rapid progression of the disease” (arthritis). This is apparently a distorted interpretation of a peer-reviewed article (to put it charitably) that was circulated in 2011. I discussed it in a previous blog post.

The second implies that contracting one of the heads of the quadriceps, the rectus femoris, causes “congestion”. Congestion, in the medical sense, is caused by an upstream blockage to the flow of blood (or lymph). A blood clot within a vein or a mass lesion (such as a tumor) pressing on it from the outside can cause congestion. It can also be caused at the capillary level through various pathological processes. Congestion is not caused by muscle contraction.

The rectus femoris in relation to the femoral artery and vein and inguinal lymph nodes.

In fact, engaging muscles (like the rectus femoris) produces a “pumping” effect on both the lymphatics and veins, which improves venous flow and relieves “congestion”. One of the reasons that we mobilize patients as soon as possible after surgery is to access the pumping effect of muscle contraction and so prevent the development of venous thrombosis (a clot forming due to venous stasis).

Diagram of veins with one-way valves demonstrating pumping action of muscle contraction.

Furthermore, the rectus femoris shares the same innervation as the other three heads of the quadriceps (the posterior division of the femoral nerve). Therefore, you cannot relax it without relaxing the rest of the quadriceps (even if you wanted to). Thus, attempting to relax the rectus femoris in isolation (to avoid “congestion”) is an example of attempting the impossible, out of fear of the imaginary, while at the same time avoiding the beneficial.

The risks of following either of these misguided cautions include: 1) diminished alignment at the knee, with potential adverse effects on the cartilage and ligaments; 2) overstretching of the hamstring tendons; 3) decreased anterior tilt of the pelvis resulting in lumbar hyperflexion (in forward bends); 4) loss of the pumping effect on the veins; etc. You get the picture.

Friends, the prevalence of knee pain is on the rise, as confirmed in the December 6, 2011 issue of the Annals of Internal Medicine.³ Basing your practice and teaching on unsound theory has the potential to contribute to this pile-up, especially considering the number of people doing yoga today. Conversely, basing it on sound theory has the potential to provide some relief.

If you do suffer from knee pain or an injury, consult your physician; always work under a physician’s guidance to manage your condition.

Great to see you all and many thanks for your support and comments on our last post! Be sure to visit us on Facebook for your free Chakra poster and e-book. See you next week, when we’ll go over a technique for improving muscle control and proprioception that you can learn in Chaturanga and then apply to any pose!

Namaste’

Ray and Chris

.1. Urquhart DM, Tobing JF, Hanna FS, Berry P, Wluka AE, Ding C, Cicuttini FM. What is the effect of physical activity on the knee joint? A systematic review. Med Sci Sports Exerc. 2011 Mar, 43(3):432-42.

.2. Racunica TL, Teichtahl AJ, Wang Y, et al. Effect of physical activity on articular knee joint structures in community-based adults. Arthritis Rheum. 2007, 57:1261–8.

.3. Uyen-Sa D.T. Nguyen, DSc; Yuqing Zhang, DSc; Yanyan Zhu, PhD; Jingbo Niu, MD, DSc; Bin Zhang, ScD; and David T. Felson, MD, MPH. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: Survey and cohort data. Annals of Internal Medicine. December 6, 2011, 155(11): 725-732.

Co-activating the Gluts and Abs in Chaturanga Dandasana

In a previous blog post, we discussed the yogic concept of satya, or truthfulness. On this, the sutras say, “When established in truthfulness, one can be sure of the results of action” (Nicolai Bachman’s translation of Sutra II.36).

I mention this because, during a recent workshop series, the question was posed, “What is the difference between caution and fear?” Participants responded without hesitation that caution stems from knowledge, wisdom, and truth. Conversely, fear and fear-based actions come from a lack of knowledge, wisdom, or truth. In other words, fear is an illusion. Caution enables; fear cripples. Satya succeeds because the generational forces of the universe, in some manner or another, line up behind it. Asatya (untruthfulness) fails because those same forces align against it.

Then, some individuals encourage and manipulate the fear of others (fear mongers). Sociopathic corporations and individuals often resort to this form of asatya when they realize that they lack the ability to compete fairly or are afraid that someone else will gain power; they fear losing control or influence over others, mainly for monetary gain. Consequently, the fear monger acts out of fear and heads down the slippery slope of asatya. For example, they might exaggerate or fabricate scientific data to cast a false light onto something or someone they fear. Ironically, in the process, they often succeed in exposing and encouraging their own fears. An entity exposed for abusing its position of trust by deliberately misleading others will lose that position. That is how the spiritually bankrupt become, simply, bankrupt.

On the other hand, Hatha Yoga is established in truth (satya). Of course it has risks--all physical activities have the risk of causing injury. Hatha Yoga has survived through the millennia because its benefits far outweigh the risks, especially when it is practiced intelligently, using common sense and an accurate knowledge of the body. For example, in an article that appeared in USA Today, basketball legend Kareem Abdul Jabbar describes his yoga experience:

"I believe that yoga is one of the reasons that I was able to play as long and as healthy as I did… Yoga is somewhat hard to quantify in terms of benefits because you see them in all the injuries you don't get… For me, I noticed improvement in my posture—that was key for me because I had been having lower back problems... After I started doing yoga positions—asanas—all that changed. My health greatly improved overall."1

Elite athletes do not spend their time cringing in fear over the possibility of injuring themselves during their activities—that would precipitate injuries. They are conscious of the risks and take steps to minimize them through the right dose of caution, scientific training and a sound knowledge of the body. If an injury should arise, they work through it and often emerge stronger. As with Jabbar, many athletes now also include yoga in their training regimen to help reduce the risk of injuries and improve their performance.

Jabbar’s positive experience with yoga and his back problem has also been validated for others in the peer reviewed scientific literature, including a study published in the November 2011 issue of the Annals of Internal Medicine, entitled “Yoga for Chronic Low Back Pain A Randomized Trial”2. This study demonstrated the safety and efficacy of yoga for the management of chronic low back pain. A summary of this article is available on the website of the Iyengar Yoga Association of the UK and The British Wheel of Yoga; you can download the full version in PDF format here.

Safety and efficacy of any intervention confirms that it is established in truthfulness or satya. Note that peer reviewed articles do not engage in fear mongering. Neither do they overstate the benefits. Instead, they elucidate the benefits and identify the risks of an intervention through a dispassionate scientific approach. This direct and honest methodology enables us, through further study, to improve the efficacy and find ways to reduce the risks. With this in mind, let’s take a look at the benefits of Chaturanga Dandasana and a tip that can be used to enhance them.

The spine illustrating tension (dorsal) and compression (ventral) relationship.

The spine as a weight bearing column.

As we evolved from quadrupeds (walking on all fours) to erect bipeds, the spine has transitioned from a suspension bridge type of structure, using tension/compression relationships, to a weight-bearing column. This change exposes the various structures of the spine to different potential stresses. For example, the “sway back” position results from a weak abdominal core. For this reason, back rehabilitation programs always incorporate abdominal strengthening exercises. In other words, conditioning the front helps to protect the back.

Chaturanga, or its variations, represent an asana that can be used to develop and condition the abdominals and to stabilize the lumbar spine. Practiced properly, it reproduces the quadruped position and temporarily relieves the biped stress on the spine. At the same time, it strengthens the abdominal core.

Chaturanga is designed to create a “staff” with the body, hence its name: “Four Limbed Staff Pose”. There is a tendency, however, to deviate from the proper position by hyperextending the lumbar and lifting the tailbone into the air in the pose. This arises from primarily using the hip flexors (including the psoas) to maintain the posture, which then tilts the pelvis forward and extends the lumbar. This tendency can be balanced and corrected by co-activating the gluteus maximus and rectus abdominis in Chaturanga. Engaging these muscles counteracts lumbar hyperextension, conditions the abdominals, and re-establishes the tension/compression relationships within the vertebral column to support the pose.

I do this by firmly engaging the abdominals and then incorporating contraction of the gluteus maximus to tilt the pelvis back and down, thus avoiding hyperextension of the lumbar spine. For those of you practicing in a Vinyasa tradition, gently tuck the tailbone to engage the gluteus maximus and contract the abdominals as you exhale and lower into Chaturanga. Note the sense of stability this provides for the lumbar. This technique can also work by engaging the same muscles in the preparatory pose, with the trunk remaining on the floor. Build and release muscular engagement gradually--this is key.

Engaging the rectus abdominis and gluteus maximus in Chaturanga Dandasana.

Here’s the Anatomy…

The rectus abdominis extends from the pubis to the cartilage of the fifth, sixth, and seventh ribs and the sternum. It draws the symphysis pubis upward, flexes the trunk of the body, and acts as an accessory muscle of expiration. The gluteus maximus originates on the back surface of the sacrum and ilium and the thoracolumbar fascia; it inserts onto the iliotibial band and the gluteal tuberosity of the femur. This muscle extends and externally rotates the femur, and it tilts the pelvis back and downward. Tilting the pelvis back and down relieves hyperextension of the lumbar through joint coupling. This is known as “lumbo-pelvic rhythm,” wherein tilting the pelvis forward or back extends or flexes the lumbar, respectively.

If you suffer from back pain, be sure to consult your physician to determine the cause; work under the guidance of a physician to manage your pain (see our full disclaimer here).

It is great to see you all again! Be sure to visit us on Facebook to download a free copy of our e-books. Check back next week when we’ll go over some pointers on the transversus abdominis and internal oblique muscles.

Namaste’

Ray and Chris

.1. John Morgan and Stephen A. Shoop, M.D., “Kareem Abdul-Jabbar Is Hot for Yoga,” News, Travel, Weather, Entertainment, Sports, Technology, U.S. & World. USATODAY.com, 27 Sept. 2003, http://www.usatoday.com/news/health/spotlighthealth/2003-09-26-jabbar_x.htm (accessed January 4, 2012).


.2. Helen E. Tilbrook, BSc, MSc; Helen Cox, BSc, MSc; Catherine E. Hewitt, BSc, MSc, PhD; Arthur Ricky Kang’ombe, BSc, MSc;Ling-Hsiang Chuang, BSc, MSc, PhD; Shalmini Jayakody, BSc, MSc; John D. Aplin, MA, PhD; Anna Semlyen, BA, MSc;Alison Trewhela, DBL, CSL; Ian Watt, BSc (Med Sci), MB, ChB, MPH; and David J. Torgerson, MSc, PhD., “Yoga for Chronic Low Back Pain a Randomized Trial” Ann Intern Med. 2011 Nov 1;155(9):569-78 PMID: 22041945