yoga

YOGA AND INJURY: IS BEING MORE FLEXIBLE ALWAYS A GOOD THING?


YOGA AND THE FLEXIBLE SPINE: A PHYSIOTHERAPY PERSPECTIVE.

Life on the west-coast involves many options for yoga practice and in no city are those choices more abundant than in here in Vancouver. It’s now rare to find a Vancouver-ite who has not practiced yoga of some form at some point. So with all this yoga, it must be good for you, right? And are there any risks associated with our developing the-more-the-better yoga culture?

I’ve practiced yoga in various forms over the past twenty years, taught classes and been a registered yoga teacher for the past eight. My own personal journey, curiosity and love for the practice led me to complete over a thousand hours of various yoga teacher trainings and develop a regular practice that continues to evolve. Though my current professional focus has shifted back to the clinical physiotherapy setting, I have stayed connected to the yoga community and remain interested as to the new trends in practice. I believe the question of whether yoga is “good for you” requires a step back to consider the traditional roots of the practice and its primary intentions and comparing this to modern-day definitions and intentions of practice and the lifestyles of present-day students. Lastly, consideration of whether flexibility is always a good thing is needed. Is it possible to be too flexible and are there injuries that can develop from this?

Yoga first originated as an eastern spiritual practice designed to develop increased comfort in the body for sitting meditation. The poses were primarily developed for Indian men, which means that they were developed for the specific bodies and present-day lifestyles of this particular group of practitioners. These practitioners did indeed spend long hours sitting, but in seated meditation, not in chairs at desks. The practice itself was meant to bring one into a more intimate relationship with one’s body such that the body could be used as a means to explore and discover the more interior layers of oneself. It also served to tame some of the superficial distractions of pain and discomfort experienced when first beginning a sitting meditation practice.

Fast forward to present-day, where the intentions for practice are so varied it would be impossible to summarize them. Yoga is now used as an form of exercise, escape mechanism, addiction, source of relaxation, social outlet, means of injury rehabilitation, spiritual practice, moving meditation, etc…The initial roots of the practice can be found somewhere in there but have been transformed to fit those of the modern-day yogi. This is an entirely necessary shift. One interesting development to consider is how yoga is practiced now though: class settings and often encouraged in great frequency. As a physiotherapist, the trends of new students signing up for 30-40 day yoga challenges coming from no prior practice poses a concern. By far the most frequent cause of injury we see from any activity is too much too soon. The class setting also has some strong psychological aspects: it is challenging to step back from poses that may not feel appropriate for your body when you have the momentum of a group carrying you along and an encouraging teacher suggesting that a pose that may be good for you, despite knowing little about your particular history or body. Does the class setting enhance the exploration of one’s own body or are there elements of it may hinder exploration and awareness of safe individual limits?

As mentioned before, an interesting question to ask may be: is flexibility always a good thing? The risks of a flexible spine are rarely discussed in yoga settings, much less recognized by health care professionals. In fact, our culture tends to view being “good” at yoga poses a universally beneficial thing, while being “stiff” is generally viewed as unhealthy and something that needs to be fixed or remedied. While teaching an injury awareness workshop to yoga teachers, I found it interesting to see how many of the new teachers reluctantly admitted to being unable to do certain poses due to pain that had developed through continued practice of said poses and remained uncertain as to what exactly it was that was causing them pain. Many therapists will prescribe you stretches for your tight muscles and yoga studios will sell you packages of yoga classes with promises to remedy the issues in your tissues. But is the picture really this simple?

Instability of the spine is an under-appreciated and under-diagnosed condition. In lieu of the fact that the medical community views instability to refer to a specific pathology requiring further medical investigation and intervention, I am going to shift to using the term “hypermobility” and loosely define this as referring to a joint that has a larger than normal range of motion and looseness in the ligamentous support and neuromuscular control of its internal system. Unfortunately, there is little research in this domain and few definitive clinical tests exist to confirm diagnosis. Imaging tests, such as x-rays, are still too gross in their current form to pick-up on the subtle differences in joint position that exist and are therefore seldom useful. As clinicians, hypermobility remains what we might refer to as a “clinical diagnosis”, meaning that it is based on a presentation of common factors pointing to a certain clinical picture in combination with our testing in the clinic.

One of the patterns we see as therapists in communities with chronic back pain stemming from hypermobility is a history of dance and/or gymnastics as a child or teenager. Often these clients will report remembering years of back pain throughout their youth as well. Ironically, it is also these individuals that tend to be attracted to yoga practice years later as many of the poses are accessible to them and they feel good stretching and moving. The risk here lies in the safe neutral zone of a joint. Joints that have a large range can be difficult to control, especially if there is not adequate attention being given to strengthening within the range available. Increased muscle tone in bodies with hypermobile joints is common as large global muscles will try to protect the joints. Stretching of these muscles feels good as it has a pain-relieving effect on the joint, muscles and nervous system, but unless this is combined with learning to change the motor control of that joint and avoiding repetitive shearing there(such as dropping into backbends), the environment will be ripe for the development of chronic pain and repetitive sprains from the lack of adequate control in these ranges. Indeed, many clients with hypermobility describe feeling “tight all the time” due to the reactive spasm of their muscles.

A thorough discussion about the treatment of hypermobility is not the intention of this blog post however I will briefly mention the interesting element that has been recognized in the use of spinal manipulation (the joint “cracking” that many associate traditionally with chiropractic treatment) with hypermobile body-types. Joint thrust techniques (manipulation) involve a release of endorphins and pain-regulating hormones directly at that joint1 and these effects apply to a hypermobile joint that is being held tight by its surrounding muscles as much as they do to a truly stiff joint. However, a study by Cook et al.2 suggested that hypermobile spines are more likely to get addicted to manipulation and seek it and find relief from it more repetitively. This can lead to increased range in the joint in the long-term and less likelihood to learn to develop adequate control of the joint, but instead seek the quick-fix manipulation provides. These are the clients we often see turning up in the clinic after years of regular spinal manipulation with their chiropractor or manipulative-trained physiotherapist asking if there might be another way, as they have spent thousands of dollars on treatment and have become very dependent on their healthcare practitioner without seeing a significant change in the long-term. Manipulation in isolation presents an excellent business-plan model for the healthcare practitioner and a poor long-term solution for clients. Don’t get me wrong, I fully support the use of spinal manipulation and use it often with my clients when I feel it is the right tool however, there is very little research to suggest that manipulation on its own is effective in resolving longer-term issues.1

Bringing the discussion back to yoga, it may seem that I am unsupportive of yoga practice, but I am most definitely not! What I do feel is needed is a return to the original intentions of the practice: to gain a deeper understanding of one’s body and oneself and yoga practice can be an exceptional way to do this. There are many excellent yoga teachers who focus on backing off edges and incorporate mid-joint range strengthening within poses. There are times in more vigorous styles of yoga when a re-evaluation of one’s practice is necessary and shifting to creating more balance in the body through intentional and specific exercises to regain stability and control in smaller and more interior ranges of movement are necessary. This may mean leaving repetitive vinyasas or extreme backbends for a period of time and focussing on spinal stabilization. My encouragement would be to develop your ability to listen carefully to the messages your body is sending you, appreciate the skill set of the practitioners you work with and what their training is in (and is not in), and seek to grow a team of people you trust to help you explore and determine what is most beneficial for you at this particular time in your life and for the present state of your body. My own, obviously-biased hope would be that this includes an excellent orthopaedic physiotherapist. See you on the yoga mat. Namaste.

REFERENCES:

  1. Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT 37:6 (2007). 290-303. Fritz JM, Cleland JA, Childs JD.
  2. Subjective and Objective Descriptors of Clinical Lumbar Spine Instability: A Delphi Study. Manual Therapy 11 (2006) 11-21. Cook C, Brisme JM, Sizer PS.