“. . . according to the Yoga Sutra (3.1), the term [Bandha] refers to the ‘binding’ of consciousness to a particular object or locus (desha), which is the very essence of concentration.”
Georg Feuerstein



Friday, December 13, 2013

Preventing Yoga Injuries vs Preventing Yoga, Part III: Joint Mobility, Stability and Proprioception

A central concept in all healing arts is that of correcting imbalances within the body. The principle of re-establishing balance can be found across all cultures from Navajo sand paintings, Ayurveda, Traditional Chinese Medicine to modern allopathy.  And anything with true healing power also has the capacity to cause injury when practiced without balance. For example, joint mobility is beneficial for a number of reasons--provided it is balanced with joint stability. In this blog post I discuss the concept of joint proprioception and its relationship to joint stability and yoga, concluding with a tip for “re-setting” muscular proprioception following hip openers. 

Proprioception refers to the sense of the relative position of neighboring body parts, such as the femoral head within the hip socket (acetabulum) as well as the muscular force utilized in movement of those parts. This is in contradistinction to exteroception, which is the perception of the outside world (like the feeling of the feet on the ground) and interoception, which is the perception of the inside of the body (pain, hunger etc). I look at proprioception as a type of “GPS” for the joints.

Joint position is detected by specialized nerve endings known as “proprioceptors” that are located within the muscles, ligaments and joint capsule and the periosteum (on the surface of the bones). These receptors communicate information about the joints to the brain via the sensory columns of the spinal cord.  Conscious sense of joint position is transmitted to the cerebrum of the brain; unconscious proprioception is communicated to the cerebellum. Figure 1 illustrates this pathway in a cross section of the spinal cord. 





Scientific studies have demonstrated that joint position sense is decreased in persons with osteoarthritis, with the consideration that reduced proprioception may play a role in the development of the disease. Indeed, exercises that improve proprioception have been demonstrated to be effective in the conservative management of osteoarthritis.  

Proprioception is also reduced in persons with joint hypermobility; exercises that improve joint position sense are also effective in reducing symptoms in this population. I suspect that proprioception may be also be a factor in those having joint pain associated with subtle instability (who do not have an identifiable cause for their pain such as arthritis, hypermobility or a structural lesion). Similarly, the diminished performance seen in certain athletes following stretching routines may be related to reduced joint position sense.

I bring this up in relation to yoga because certain individuals experience soreness in their hips following hip opening poses.  Understanding that this pain may be related to decreased proprioception, I have been using a simple technique to re-establish joint position sense following these poses. For example, I worked with several practitioners during the Blue Spirit Intensive who had this type of hip soreness. Following a sequence that led to Full Lotus, we applied the technique, which “resets” the joint position sense in the hips. After the “reset”, these folks noticed that the hip pain they typically felt was gone, with this benefit remaining throughout the day.

This leads me to believe that some of the hip pain experienced by practitioners may be related to a reduction in muscular proprioception after stretching, which persists as a subtle form of instability during other activities following practice. Furthermore, the soreness appears to be relieved by a technique to increase proprioception that involves co-activating the muscles surrounding the hip joint at a midpoint of the joint's range of motion.

Here’s the technique…

Following a hip opening sequence, and before Savasana, I utilize an intermediate version of Warrior II, where the forward knee and hip are not flexing deeply (figure 2). Then I “co-activate” the hip muscles in the forward leg (co-activation involves simultaneously contracting muscles that have opposite actions). The cue for this is to imagine pressing the inside of knee into an immoveable object while at the same time pressing the outside of the knee into a similar object (the knee remains centered and does not move). This engages both the hip adductors and abductors, as well as the internal and external rotators in a position where the joint is in the mid-range of motion. Done properly, this cue should give a feeling of stability in the hip joint.

Since it is a neurological process, this technique does not require strong muscular contraction; I only utilize just enough strength to feel the muscles engage and the hip stabilize. Furthermore, the cue only requires a short duration. I have been using 20 seconds, repeated twice on each side. The effect is a bit like “resetting” a GPS that has gone out of its normal range. Figures 3-5 illustrate the muscle groups involved with the arrows demonstrating the direction of force. Visualization of the muscles helps in this process.

Figure 2: Warrior II intermediate version. I use this for training proprioception.

Figure 3: Co-activating the hip adductors, abductors and rotators in Warrior  II.

Figure 4: Co-activating the hip adductors, abductors and rotators in Warrior  II.

Figure 5: Activating the deep external rotators of the hip in Warrior II.


Thanks for stopping by. We hope that you enjoy this tip on training proprioception of the hip joint. Note that if you have persistent hip pain or other symptoms, be sure to consult a health care provider who is appropriately trained and qualified to manage such conditions. 

If you would like to learn more about anatomy, biomechanics and yoga, feel free to browse through The Key Muscles and Key Poses of Yoga. Also, check out the Yoga Mat Companion series, which contains many examples of co-activation (including the one in this post). Many thanks for your support by sharing us on Facebook, Twitter and Google Plus as well.

Namaste'

Ray and Chris



References:
  1. Wolf JM, Cameron KL, Owens BD. “Impact of joint laxity and hypermobility on the musculoskeletal system.” J Am Acad Orthop Surg. 2011 Aug;19(8):463-71.
  2. Smith TO, Jerman E, Easton V, Bacon H, Armon K, Poland F, Macgregor AJ. “Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis.” Rheumatol Int. 2013 Nov;33(11):2709-16.
  3. Smith TO, King JJ, Hing CB. “The effectiveness of proprioceptive-based exercise for osteoarthritis of the knee: a systematic review and meta-analysis.” Rheumatol Int. 2012 Nov;32(11):3339-51.
  4. Sahin N, Baskent A, Cakmak A, Salli A, Ugurlu H, Berker E. “Evaluation of knee proprioception and effects of proprioception exercise in patients with benign joint hypermobility syndrome.” Rheumatol Int. 2008 Aug;28(10):995-1000.
  5. Lund H, Juul-Kristensen B, Hansen K, Christensen R, Christensen H, Danneskiold-Samsoe B, Bliddal H. “Movement detection impaired in patients with knee osteoarthritis compared to healthy controls: a cross-sectional case-control study.” J Musculoskelet Neuronal Interact. 2008 Oct-Dec;8(4):391-400.
  6. Sharma L. “Proprioceptive impairment in knee osteoarthritis.” Rheum Dis Clin North Am. 1999 May;25(2):299-314, vi.
  7. Liikavainio T, Lyytinen T, Tyrväinen E, Sipilä S, Arokoski JP. “Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis.” Arch Phys Med Rehabil. 2008 Nov;89(11):2185-94.
  8. Lauersen JB, Bertelsen DM, Andersen LB. “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials.” Br J Sports Med. 2013 Oct 7.
  9. Caplan N, Rogers R, Parr MK, Hayes PR. “The effect of proprioceptive neuromuscular facilitation and static stretch training on running mechanics.” J Strength Cond Res. 2009 Jul;23(4):1175-80.
  10. Higgs F, Winter SL. “The effect of a four-week proprioceptive neuromuscular facilitation stretching program on isokinetic torque production.” J Strength Cond Res. 2009 Aug;23(5):1442-7.
  11. Handrakis JP, Southard VN, Abreu JM, Aloisa M, Doyen MR, Echevarria LM, Hwang H, Samuels C, Venegas SA, Douris PC. “Static stretching does not impair performance in active middle-aged adults.” J Strength Cond Res. 2010 Mar;24(3):825-30.
  12. Wu Q, Henry JL. “Functional changes in muscle afferent neurones in an osteoarthritis model: implications for impaired proprioceptive performance.” PLoS One. 2012;7(5): Epub 2012 May 14.
  13. Shu B, Safran MR. “Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability.” Clin Sports Med. 2011 Apr;30(2):349-67.
  14. Smith MV, Sekiya JK. “Hip instability.” Sports Med Arthrosc. 2010 Jun;18(2):108-12.
  15. Holla JF, van der Leeden M, Peter WF, Roorda LD, van der Esch M, Lems WF, Gerritsen M, Voorneman RE, Steultjens MP, Dekker J. “Proprioception, laxity, muscle strength and activity limitations in early symptomatic knee osteoarthritis: results from the CHECK cohort.” J Rehabil Med. 2012 Oct;44(10):862-8.

9 comments:

  1. In relation to hips in such asanas as varrior II. Is is reasonable to aim at having both spina iliaca ansterior superior in one surface in parallel with long edge of the mat? I supose that it is important to put them on the same level/hight but since the front leg is in external rotation, the second one is in internal, it is difficult to move back the spina iliaca anterior superior of the back leg . Hope you understand what I mean:)

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  2. Thank you Ray and Chris once again for a great read! Can you use this technique for the shoulder joint? If so, how would you do it?

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    1. You're welcome, Martine--glad to hear you enjoyed this article. For the shoulder, I use co-activation of the rotator cuff (and associated muscles). The cue for this in down dog is to press the base of the index finger into the mat (pronate the forearm) while at the same time externally rotating the shoulders. This combines internal and external rotation of the joint. Can start with child's pose and the hands outstretched in front on the mat. Should also engage triceps to straighten elbow (the long head of the triceps crosses the shoulder joint and contributes to stability). I also use Garudasana arms to strengthen the rotator cuff; I engage the muscles by gently pressing the elbows together. Can also use Warrior II with internal and external rotation of the shoulders in a midrange of motion. Bear in mind that the shoulder is inherently less stable than the hip, so this takes a bit more practice. The cue above for the hip has worked very quickly in the practitioners I've worked with--which has been very satisfying.

      Best~Ray

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  3. Great blog post - we need to pay way more attention to body awareness in Yoga. Odd that we haven't. I have some ideas that I hope you will consider, but i do not want to take away from the important messages in your post, or the excellent techniques you suggest that so obviously help people.
    There is growing belief of the complex interactions of proprioception, interoception, body awareness, body image and pain. So far the problem in the scientific realm is that we don't have standardized measures of these things. I think, as you point out, that in Yoga we can do a very good job of connecting people to what is important in these systems.

    Please consider that the typical definition of proprioception is the relative position of the physical body, and that some add that proprioception includes awareness of movement. Typically interoception is considered the physiological state of the physical body. This would usually include muscle tension, blood pressure, pressure within body cavities, tension in organs (muscles, tendons, bladder, … using the biological definition of organ here, rather than the common one) .
    If we consider these definitions, it's interesting that Yoga practices often pay far more attention to proprioception than interoception. And as you mention, this can be problematic. Research shows that distortions in body awareness or body image, and poor ability to feel sensations in the body are related to persisting pain Sometimes one of the key ways to decrease pain is to provide the individual with experiences that increase or normalize one's ability to feel the body (in an 'more accurate' manner).
    On another note, proprioception is a function involving both the peripheral and central nervous systems. As such, it is important to discuss proprioception from a systems and organism view, rather than only a peripheral view. Proprioception is not synonymous with the neural inputs from the body tissues. Just as what happens in the eyes is not synonymous with what we 'see'.
    As such, conscious sense of joint position is not transmitted to the brain. It is created in the brain.
    Going further on this point, pain is a human experience that is not synonymous with activity in nociceptors or peripheral tissues. (as an important aside, this points to a significant flaw in the spinal cord transection diagram. There are no pain pathways in the spinal cord. Although the artist may have know this, this simplification of the human experience of pain, or of joint position, is something we as Yogis must stop perpetuating - I believe.)

    The technique provided here is so wonderful - it influences so many aspects of the individual in positive ways.
    Generally it can foster a sense of safety, on top of the feeling of stability.
    It 'bombards' the brain with 'normal' sensory input, allowing the nervous systems to create 'better' motor outputs.
    It teaches better ability to find the right amount of effort and letting go. And my guess is this might spill over into breathing.
    The same technique could ground, energize, and decrease the fire in those experiencing imbalances in their constitution.
    Yet in the end, when it changes a person's pain, the thing we know for certain is that it altered the conclusion that something dangerous was happening - and that is good.

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    1. Good points Neil! Delighted you enjoyed the post. Thanks for commenting--nailed it well, I especially like the last para. Very good to see your comment; opens up new ideas in an emerging field. I'm especially interested in the concepts of pain generation and relief. Only comment from me is on the spinal cross section--we do mention the pain pathway in the lateral spinothalamic tract. I think good proprioception helps with joint congruency and this may account for the decrease in pain with this type of training.
      Good to see you here and thanks for a well thought out comment~Ray

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  4. Great read, love this blog. Namaste! :)

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  5. Just bought your two first books on Amazon, looking forward to receiving it..
    Namaste

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  6. HOLA RAY HE COMPRADO CASI TODOS TUS LIBROS EXCEPTO DOS QUE AL PARECER NO SE HAN PUBLICADO EN ESPAÑOL AQUI EN MÉXICO, SON: " ANATOMY FOR BACKBENDS AND TWIST" Y "ANATOMY FOR ARM BALANCES AND INVERSIONS"
    ESPERO TENER NOTICIAS EN EL MOMENTO QUE SE PUBLIQUEN EN ESPAÑOL Y PODERLOS COMPRAR POR QUE HAN SIDO DE INVALUABLE AYUDA EN MI PRACTICA.
    FELICIDADES Y MUCHAS , MUCHAS GRACIAS POR COMPARTIR TUS VALIOSOS CONOCIMIENTOS.
    NAMASTÉ.

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  7. Thanks so much for all the great information.

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