This is an interview with Phil Rolfe, a physical therapist in Boulder, Colorado, who works at a clinic where he sees primarily spine patients. Boulder is quite the mecca for yoga. There is a
studio on every block, a teacher training happening every week, and every style of yoga. Named one of the top 10 "Fantastically Yoga Friendly Towns" by Yoga Journal, Boulder boasts over 40 yoga studios (for a population of about 100,160).
Rob: What's the trend you're seeing in your work with respect to yoga students and teachers?
The spectrum of my patient population consists of the very active athletes to those struggling to stay ahead of a degenerative process, such as osteoarthritis. Within that continuum, I see patients injure themselves specifically their back and pelvis doing yoga on their own or in a class as a student or teacher. I often see pelvic and lumbar dysfunction, which can be thought of as an asymmetric presentation of the lumbar vertebrae often including the pelvis. These dysfunctions can be corrected with manipulations (high velocity, low amplitude), mobilizations, or muscle energy techniques. I also see, with yoga patients who are experiencing back or pelvic pain, a shutdown of their local stability system, along with joint hypermobility. The key to treatment is to correct the dysfunction and assess for gross motor strength and flexibility issues. I test whether their spinal stability system is functioning, and educate them how to reconnect with this motor control system.
What are some of the common risks of injury you're seeing in yoga practitioners
From my perspective, lower back and pelvic dysfunction resulting in pain can be seen with yoga practitioners. In the setting in which I practice, I rarely see a patient who does yoga struggling with upper or lower extremity issues. However, I've read the recent New York Times article by William Broad regarding hip pain and yoga, detailing the dangers to the hip complex specifically with regard to women. FAI (femoroacetabular impingement), discussed at length in this article and a cause of early degenerative hip joint changes, is a problem of the hip that is caused by abnormal hip joint architecture. This and other problems can result in different patterns of joint wear and tear. Now, if a yoga practitioner with one of these issues is performing a pose that impacts these abnormalities by pushing the hip range of motion to its limits, specifically in hyper-flexion, the long term effects may be disastrous. It's good to note that FAI is not only impacted by yoga, and in my limited search, there is no research to implicate yoga; I did find quite a bit of research regarding running, hockey, and soccer correlating these sports to FAI. Ultimately our bodies need a balance of strength and flexibility and I think that this concept provides the basic construct to most healthy exercise programs. I consider excessive flexibility to be risky and may lead to a length tension ratio problem: too much length in a muscle reduces the tension that helps maintain normal joint mechanics. It can also change the normal forces in the capsule that surrounds a joint. Keep in mind that 'more is not always better' and that the threat of excessive flexibility needs to be considered with regard to the peripheral joints, as well as the spine.
To be smart and safe in doing yoga, what do you recommend?
The answer to this question will be within the definitions of flexibility, strength and stability.
Flexibility: flexibility is defined as the ability of an individual to move his or her joints through a full range of motion. Flexibility helps individuals to stretch without straining themselves. I don't recommend attaining or striving for excessive flexibility. This would remove the body's soft tissue restraints, muscular and ligamentous, such that joint stability may be compromised. It would be a rare occurrence that large amounts of flexibility are functionally necessary. I suppose that certain sporting activities, such as gymnastics or dance, require more musculotendonous length, but I can tell you that I have seen multiple patients from these sports who ultimately needed hip rehabilitation and/or surgical intervention at a relatively young age.
Strength defined by Merriam Webster is the capacity for exertion or endurance, and the power to resist force. Strength involves utilization of the prime movers or global mobility system to move the skeletal system. Too much tightness of a muscle can provide additional irritation to the joint system that it surrounds; conversely, too little length tension lessens the amount of joint support. Global mobilizers, which are gross motor movers, provide support to the stability mechanisms.
With regard to the spinal column, one of the most important concepts to understand is that strength is not equal to stability. For example, crunches or superman exercises do not make your back stable. In my experience with yoga, the functional strengthening component is excellent, the lengthening or flexibility aspect is great as well--in moderation; but there is no spinal stability work to keep the spinal segments safe. We need to be careful not to sacrifice stability for flexibility, the results can be painful. In my opinion, it would be prudent to consider stability training for yoga practitioners; certainly if they are experiencing spine pain.
Stability is medically defined as the ability of the spinal column, under physiologic loading, to maintain its normal configuration. Stable behavior is critical for the spine to bear loads and allow for safe movement. Stability involves a muscular system called the local stability system, which is a system that has a direct connection to the spine. These muscles are not prime movers; they are lower threshold muscles that essentially provide a stiffness around the spine. These muscles do not get tight and they do not offer significant movement of the spine. I think of spinal stability as the ability of the spinal vertebrae to stay within a neutral zone. When a spinal vertebra slides on another (sheer forces/out of neutral zone), there is an impact on the peripheral nerves as they travel through the boney opening of the vertebrae (foramen). This will irritate the nerve, cause an inflammatory reaction, and ultimately pain. The pain can be local or peripheral.
The pelvic floor can be a place to begin with stability work with the spine. Through engagement of the Kegel, we can connect with the musculature that provides stability to the lumbar spine and pelvis. Again, these are lower threshold muscles. The old 'pull your belly button to your spine' mantra is confusing the categories of muscles: expecting the global mobility system to go to work for stability system, and that simply is not effective. Remember that strength and stability are not equivalent.
Are there three tips to developing a safe practice?
1. Excessive flexibility should not be the goal of the yoga practitioner.
2. With back pain, strength does not equal stability.
3. If it hurts, don't do it. Pain can inhibit the stability system.
How would you improve the safety of yoga in teacher training programs?
1. Teachers should be taught the proper hip mechanics to avoid FAI.
2. Yoga teachers should understand how to avoid sheer force compression, by teaching their clients to engage their local stability system.
3. And again, flexibility is a good thing if not taken to excess.
Editor: Alice Trembour