preventingyogainjuries

8/7/2019 preventingyogainjuries

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1YOGA INJURIES

Abstract: o obtain an initial estimate o the extent, nature, and causes o Yoga-related injuries, we invited 33,000 Yoga teach-

ers, Yoga therapists, and other clinicians to participate in a 22-question survey. Te survey was conducted with the cooperation othe International Association o Yoga Terapists (IAY), Yoga Alliance, and Yoga Spirit. 1,336 responses came rom 35 countriesbetween May and October o 2007. A majority o participants believed that the most common and the most severe injuries occurredin the neck, the lower back, the shoulder and wrists, and the knee. Poor technique or alignment, previous injury, excess eort, andimproper or inadequate instruction were the most commonly cited causes o Yoga injuries. Individualsanas were linked withparticular injuries in a highly specifc way. For example, neck injuries were attributed to sirssana (headstand) andsarvngsana(shoulderstand); lower-back injuries were associated with orward bends, twists, and backbends; shoulder and wrist injuries werelinked to adho mukha svansana (downward-acing dog) and variations o plank pose (e.g., chaturanga dandsana, our-limbedsta pose andvasisthsana, side plank pose); and the knee was believed to be most requently injured in vrabhadrsana (warriorpose) I and II, virsana (heros pose,) eka pda rajakapotsana (one-legged king pigeon pose) andpadmsana (lotus pose).

Keywords: Yoga, injury, risk

Introduction

Most authorities seem to agree with the AmericanAssociation o Orthopedic Surgeons that the rewards obasic Yoga outweigh the potential physical risks, as long asyou take caution and perorm the exercises in moderation,according to your individual exibility level.1 Nonetheless,an upturn in injuries has been noted in parallel to the in-creased popularity o Yoga, and a variety o actors are gener-ally, but nonempirically, listed as the cause.2 I Yoga is to be

welcomed intothe healing repertoire o medicine, then inaddition to demonstrating its benets, it is incumbent uponthe Yoga community to estimate its liabilities, and deter-mine, to the extent possible, how to do no harm.Understanding the causes and requency o Yoga-related in-juries is important or several reasons: 1) It will better allowthe Yoga and healthcare communities to responsibly evalu-ate the benets and risks o Yoga, 2) it will help protect prac-titioners and prevent injuries, and 3) it will thereore clearthe way or intelligent and inormed acceptance o Yoga bythe wider healthcare community.

Yoga has been implicated as having harmul consequenc-es in a number o academic and lay-press publications.1-6Yoga Journalpublished an excellent article on this topic inJune 2003, entitled Insight rom Injury: I the Practice oHatha Yoga Was Meant to Heal, Why Are So Many YogisGetting Hurt?4 Author Carol Kruco underscores the issueo attitude right away, saying that she learned the hard waythat there is no showing o in Yoga. Ater an injury whilebeing photographed, she learned respect or the importanceo warming-up, proper sequencing, and having the right at-

titude. Kruco quotes many teachers and experts in theeld, who note that Yoga injuries are most commonly causedby overzealousness and unrealistic expectations in students,inadequate training o teachers, poor technique, and largeclasses. Kruco notes that the market-driven aspect o Yogahas spawned a scramble or instructors as well, resulting insome teachers with inadequate training being hired.

Pamela Pauls article When Yoga Hurts, appearing inimemagazine in October 2007,3 echoes these issues. Paulargues that the increased attendance at Yoga classes will logi-cally lead to an increase in the overall number o Yoga-related

Yoga Therapy in Practice

Understanding and Preventing Yoga Injuries

Loren M. Fishman, MD,1 Ellen Saltonstall, RYT,2Susan Genis, RYT, Esq.2

1.Columbia College of Physicians and Surgeons 2. New York, New York


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2 INERNAIONAL JOURNAL OF YOGA HERAPY No. 18 (2009)

injuries. Paul also mentions that new Yoga students may beout o shape and expect Yoga to be easy, leading to injuryrom over-eorting. Here, the teachers experience and guid-

ance is crucial. Paul points to lack o adequate teacher train-ing as a actor in the increase in injuries.

Te imearticle cites 13,000 documented Yoga injuriesover a three-year period. With an estimated 14,000,000 peo-ple practicing Yoga, that is only one injury in a thousand. Ithis statistic is accurate, that makes Yoga saer than many othertypes o exercise. However, that gure was reported by themedical community (emergency rooms and physicians), notthe by the Yoga community. Tereore, it is unclear whetherthe gure ully reects the experience o Yoga practitionerswho may not seek medical care or Yoga-related injuries.

Te attempt to investigate Yoga injuries is made difcult

by many actors: the absence o any ormal reporting proto-col within the Yoga community, the wide range o severity oinjuries, and the challenge o identiying the specic causeso any injury. Yet, there is little doubt that such injuries dooccur. At the very least, they impair the experience o Yoga;and, at the other end o the spectrum, can lead to perma-nent injury, disability, and even death.2

Te Survey

o initiate the process o sel-scrutiny, we created a 22-item multiple-choice anonymous online questionnaire. Wedesigned the survey over a our-month period, securing theopinions and advice o many Yoga teachers and therapists inthe international community, as well as design advice romstatisticians and researchers.

With the cooperation o three international organiza-tions (IAY, Yoga Alliance, and Yoga Spirit) and variousother sources o Yoga teacher and therapist email addresses,we sent the URL o anonline survey to more than 33,000Yoga teachers and therapists.

Ater demographics, the survey centered on the rangeand severity o Yoga-related injuries and what the teachers/

therapists believed to be their major causes. We asked re-spondents to share opinions based on their actual experience(not what they had read or been told) with their students,their clients, and themselves. Respondents were asked to re-port injuries only i they were reasonably sure that the prac-tice o Yoga caused them, whether they occurred in theirsessions, at home, or in another practitioners presence. Teorder o the answer choices to the multiple-choice questionswas randomized in each individual presentation, to mini-mize response bias. Respondents were not compensated inany way or participation.

Respondents

Tere were 1,336 responses to the survey, reecting a

response rate o 4%, rom a total o 34 countries. Te ma-jority o responses came rom the United States (81.4%),Canada (11.7%), Australia (1.3%), and the UK (1%).Tere were ewer than ve responses each rom the other30 countries (Barbados, Brazil, China, Costa Rica, Finland,France, Germany, Greece, India, Iran, Ireland, Italy, Japan,Malaysia, Mexico, Netherlands, New Zealand, Norway,Peru, Poland, Portugal, Puerto Rico, Saudi Arabia, SouthArica, South Korea, Spain, Sweden, Switzerland, urkey,and Venezuela).

Te non-exclusive vocational status o responderswas: Yoga teacher (91%), massage therapist (8%), body-

worker (8%), personal trainer (7%), physician (2%), andother (41%). Te number o years the responders had beenteaching Yoga/using it in their practice t a normal distribu-tion curve centered reasonably well at 5-10 years: 0-2 (9%),2-5 (20%), 5-10 (27%), 10-20 (20%), 20-30 (11%), >30 (7%), and other (6%). Te other category includedboth teachers-in-training and retired teachers and therapists.Most respondents saw either 11-30 (35%) or 31-75 (35%)clients/patients per week. About 18% saw 1-10 clients,10% saw 75-150, and 2% saw over 151.

Respondents were invited (but not required) to writein the style or tradition o Yoga they identied themselveswith. Respondents listed a variety o Yoga styles or tradi-tions, as ollows: Hatha (16%), Vinyasa (10%), Iyengar(7%), Anusara (6%), Ashtanga (5%), Kripalu (5%), andFlow (3%). Te authors believe that the Hatha designa-tion generally indicates teachers and therapists who considerthemselves eclectic, having no rm and/or exclusive ties toany particular school o Yoga.

Opinion Survey Questions and Results

Please estimate what you believe to be the percentage

o people who do Yoga (primarily) or each o the ol-lowing reasons. Averaging responses, the sample believedthat the percentage o students/clients practicing primarilyor each o the ollowing reasons were: tness and generalhealth (53.4%); peaceulness, liberation, or a more enlight-ened lie (18.2%); remedy or specic medical solutions(16%); remedy or emotional problems (9.7%); and otherreasons (2.7%).

Are there more Yoga injuries today than previously? 39%o respondents answered yes, 36% answered no, and 25%


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3YOGA INJURIES

said that they did not know. Several individuals replied in thecomments box that there could be no such thing as a Yogainjury, because properly executed, Yoga causes no injuries.

Why are there more injuries nowthan in the past? Onlythose who answered yes above were given this question.Respondents could select multiple reasons, and the ollow-ing percentages o participants endorsed each reason:

Excessive student efort 81.4%Inadequate teacher training 68.2%More people doing Yoga overall 65.4%Unknown pre-existing conditions 59.5%Larger classes 47.0%

In your opinion, what injuries are most likely to result rom

Yoga practice or any reason (list up to fve)? Respondentswere asked to write in answers so as not to bias their re-porting. Tis approach provided signicant inormationor designing uture surveys, but poor odder or precisestatistical analysis. Many o the answers gave generalizationssuch as strains and/or tears o muscles/ligaments/tendons,or injury to joints. When a particular part o the body wasmentioned, the top ve were neck, shoulder, low back,knee, and wrist. Te data in able 1 below were tabulatedmanually, noting the injury sites most oten mentioned.While not denitive, it highlights areas o concern.

How requently might Yoga practice result in each o theollowing injuries or conditions on a scale o 0 (never)to 5 (most requent)? Respondents were asked to give a

number rating or each o the potential injuries listed. able2 shows the average rating or each, listed in descendingorder o requency.

Injury Site Numbero TimesMentioned

Neck or cervical spine 674

Shoulder (including rotator cu) 661

Low back (including sacrum, SI joint,sciatica)

644

Knee 597

Wrist 414

Back or spine (any area) 392Hamstring 332

Hip 112

Leg (including ankle or oot) 64

Groin 52

Other areas mentioned less requently: Elbow, headaches,nausea, emotional (or psychological), nervous system.

Table 1. Areas o the body most likely to sustain a Yoga-relatedinjury.

Table 2. Relative requency o injuries resulting rom Yogapractice.

Injury or condition Avg Frequency - on a scale

o 0 (never) to 5 (most

requent)

Low back 3.79

Shoulder or rotator cu 3.23

Wrist or hand 3.13

Knee 3.05

Hip problems 2.69

Hamstring 2.57

Neck 2.47

Headaches 1.99

Groin strain 1.56

Lower leg or oot 1.50

Pregnancy issues 1.24

Toracic or rib pain 1.04

Bruise rom all 0.96

Cardiac problems 0.81Fracture 0.56

Eyes 0.54

Stroke 0.40

What are the most serious injuries (disabling and/oro long duration) that you have seen? Tis question wasdesigned to get an overview, rather than hard numbers.

Respondents were again asked to write in answers. Weneglected, however, to remind respondents that answersshould be based upon injuries resulting rom Yoga practice.Instead, many answers described serious injuries or chronicconditions that prompted people to take Yoga. Oten it wasunclear whether injuries cited had resulted rom Yoga orrom some other source. A substantial number o respon-dents noted that they had seen no serious injuries as a re-sult o practicing Yoga (see None below in able 3). Intallying the write-in answers or able 3, we attempted toinclude only those relating to injuries that occurred during


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Yoga practice. Te results may be helpul in reminding bothteachers and students o the areas o the body at greatest riskor serious injury.

dents to rate the likelihood o a list o actors to cause aYoga-related injury, gave similar results.

How likely, on a scale o 0 (never) to 5 (most likely),is each o the ollowing to cause an injury during Yogapractice? Respondents were asked to give a number ratingor each o the actors suggested as possible causes o injury.able 4 below shows the average rating or all responses re-garding each actor.

Table 3. Most serious injuries (disabling or o long duration).

Area o Injury Numbero TimesNoted

Percentage

Low back, including sacro-iliac, sciatica

231 19.44%

Shoulder, including rotator cu 219 18.43%

Knee 174 14.65%

Neck 110 9.26%

Hamstrings 107 9.01%

Wrist or hand 67 5.64%None 66 5.56%

Back or spinal (unspecied area) 49 4.12%

Hips 44 3.70%

Discs (herniated) 43 3.62%

Groin 25 2.10%

Fractures (various locations) 17 1.43%

Lower leg or oot 14 1.18%

Cardiac problems 5 0.42%

Stroke 4 0.34%

Eyes 3 0.25%

Pregnancy issues 3 0.25%

Toracic or ribs 3 0.25%

rauma or bruise rom alling 3 0.25%

Headaches 1 0.08%

In your opinion, what are the three most common causeso Yoga injuries? Respondents were rst asked to write in

answers to avoid the survey authors bias. (In a separatelater question, they were asked to consider specied causes).Although the wording varied, the causes most oten citedwere (1) overzealousness, ego, or excess eort; (2) poor tech-nique and/or alignment; and (3) improper or inadequateinstruction, and/or poorly trained teachers. Tese responsest airly well with opinions expressed in the lay press. 1,3,4However, poor alignment has not, to our knowledge, beenmentioned in any previous published discussion o Yoga in-juries. Te write-in answers do not yield easily quantiablestatistics. However, the ollow-up question, asking respon-

Table 4. Relative likelihood o various actors to cause a Yoga-related injury.

Factor that Might Cause Injury Average Likelihood -

on a Scale o 0 (Never)

to 5 (Most Likely)

Ego 4.37

Excess eort 4.31Poor technique/alignment 4.16

Inadequate instruction 4.13

Improper instruction 4.10

Poses done too ast 3.67

Pressure rom teacher/group 3.53

Overly loose muscles/ligament 3.50

Undisclosed prior condition 3.40

Poor warm up 3.24

Overly tight muscles/ligaments 2.98

Class size 2.96eaching sequence 2.89

Fatigue 2.75

Poor overall conditioning 2.71

Poses held too long 2.40

Osteoporosis 2.04

Overweight 1.96

Falls 1.96

Advanced Age 1.88

Prop deect 1.40

For each listed injury, please write in any Yoga pose youmost oten associate with causing it. As with several ear-lier questions, the write-in responses were so varied that wecannot give detailed comprehensive summary statistics. Itis possible, however, to glean which sana or categories oposes were most requently associated with certain injuries.Tese are shown in able 5 below.


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5YOGA INJURIES

Preventing Injuries in Yoga

We will now consider how a Yoga teacher, Yoga thera-

pist, or student can prevent the most commonly reportedYoga injuries. Te recommendations below address the ourtop-stated causeso injury: poor technique and/or alignment,previous injury or condition, excess eort, and inadequateor improper instructions rom teachers. Tese our causesare o course interrelated, and addressing any one will otenbe a gateway to addressing the others.

Te specic instructions included below come rom ourcombined training in Iyengar Yoga and Anusara Yoga;weacknowledge that other styles may approach these posturesdierently. While many o the suggestions will be amiliar,and ollow basic principles o biomechanics and ahims

(non-harming), it is important to reect on how consistentlythey are being applied by teachers and students in practice.

Preventing Injuries in Yoga When Prior Injuriesor Conditions Exist

With regard to previous injuries or conditions as a causeo new injuries, teachers and studios must ask, and studentsneed to inorm their teachers, about any pre-existing condi-tions. Nevertheless, these conditions may remain undisclosed.Tereore, teachers should be proactive in mentioning anycontraindications o a pose. eachers must have the requisiteknowledge o the body to know how to adjust a studentspractice to avoid risk related to preconditions. In each sec-tion below, we have noted when particular care is advisable.

Preventing Injuries in the NeckTe cervical spine is the most vulnerable part o the

spine because it is the most mobile. Te two types o posesin which the most care is needed to protect the neck arebackbends and inversions.

In backbending, vertebral compression and nerve im-pingement occurs when a Yoga student is too aggressive,thrusting the head and neck back in bhujangsana (cobra

pose), rdhva mukha svansana (upward-acing dog pose),or ustrsana (camel pose). Tis is particularly true in posessuch as ustrsana in which gravity will play a part in takingthe head back. Te key instruction (and awareness) that willprotect the neck is to arch the head back only ater achievingthe maximum possible arch in the thoracic spine. It is alsohelpul to maintain some muscular tone in the ront o theneck. With these protective actions, the arching movementis spread evenly through the vertebral column.

Te inverted poses most implicated or neck injuries aresirssana (headstand) and sarvngsana (shoulderstand). Inable 5. Matching Injuries and sana

Injury Frequently Associatedsana

Neck sirssana (headstand), sarvngsana (shoulder-stand), halsana (plow pose)

Shoulder/

Rotator cu

chaturanga dandsana (our-limbed sta pose),adho mukha svansana (downward-acingdog), vasisthsana (side plank pose), rdhvadhanursana (upward-acing bow), all binds

Low back,

sacrum, sacro-

iliac joint

seated and standing orward bends, twists,backbends

Knee virabhdrsana (warrior pose) I and II, utthitatrikonsana (extended triangle pose) padmsana(lotus pose), eka pda rajakapotsana (one-legged king pigeon pose), virsana (hero's pose)

Wrist/Hand adho mukha svansana (downward-acing dogpose), chaturanga dandsana (our-limbed stapose), adho mukha vrkssana (handstand), baksana(crow pose), vasisthsana (side plank pose)

Hamstring paschimottnsana (seated orward bend),uttnsana (standing orward bend), parsvot-tansana (intense side stretch pose)

Hip utthitatrikonsana (extendedtriangle pose),virabharsana (warrior pose), eka pda rajaka-potsana (one-legged king pigeon pose), twists

Lower leg/oot vrabhadrsana (warrior pose), balancing

poses, jumping poses, virsana (hero's pose),padmsana (lotus pose)

Groin hanumansana (monkey pose), utthitatrikonsana (extendedtriangle pose) andother wide-leg standing poses, lunges, baddhakonsana (cobbler's pose),upavishta konsana

Toracic/Rib twists, backbends

In pregnancy twists, inversions, dhanursana (bow pose),salabhsana (locust pose), nvsana (boat pose)

Fracture adho mukha vrkssana (handstand), balancingposes, orward bends

Eyes inversions, orward bends (standing)

Cardiac inversions, ast vinyasa practice, excess eort orheat, arms overhead in standing poses, poses that

constrict chest or abdomen, improper breathing

Stroke inversions, ast vinyasa practice, excess eortor heat, arms overhead in standing poses,

improper breathing

rauma, alls sirssana (headstand), balancing poses


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sirssana, it is essential or the student to understand howto use the arms and shoulders to support the bodys weight.Pressing the arms down and liting the scapulae elongate

the neck even while weight-bearing. Without this supportrom the oundation o the pose, excessive weight on theneck vertebrae may cause injury. In sarvngsana, blanketsupport may be required to prevent excess exion o theneck. When the pose is perormed at without blanketsbeneath the shoulders, the vertebrae o the neck are orcedinto 90 degrees o exion, pinned to the oor by the bodysweight. Ligaments, tendons, discs, and muscles connectingthese vertebrae are all at risk. With the shoulders and upperarms elevated on olded blankets, less exion o the neckvertebrae is required, and inevitable pressure on this areawill be shared by the shoulders. Students must prepare by

strengthening and stretching the neck and shoulders beoreattempting these ully inverted poses. In addition, abdomi-nal strength and vigorous stretch in the legs signicantlyreduce collapse o the body weight into the neck.

Preventing Lower-Back Injuries in Forward BendsConsiderations o the anatomy o the spine, pelvis, and

legs are relevant here. Te risk inmost orward bends, suchas uttnsana (standing orward bend) or pascimottnsana(seated orward bend), is that tightness in the hamstringswill restrict the pelvis rom tilting, causing excessive exionin the lumbar spine rather than exion o the hips. Tis ex-cessive lumbar exion could result in sprains o spinal liga-ments or muscles, such as the dorsal and lumbar paraspinalmusculature and quadratus lumborum, and could also causedisc herniation, or osteoporotic wedge racture. Here, previ-ous injury, excess eort, inadequate instruction, and poortechnique are a treacherous combination.

Students will benet rom the instruction to tilt thepelvis orward toward the legs as a rst step to any orwardbend, especially one in which gravity will increase the inten-sity o the pose. Broadening the thighs helps this pelvic tilt,as does bending the knees and extending the thoracic spine

away rom the pelvis.Students also can be instructed not to pull aggres-sively with their arms to go deeper into a orward bendingpose. In uttnsana, or example, support such as a table, achair, or two blocks could be used or the hands, to lessenthe weight o the upper body as it descends and to discour-age aggressive pulling.

Proper preparation is also a key actor. A hip-exionpose with the spine supported, such as supta padngusthsa-na (reclining big toe pose), is an excellent preparation ormore demanding orward bends such as uttnsana and

pascimottnsana. Tis supine pose will lengthen the ham-strings while providing support and proper length or thespine. eachers must take note o which students need this

preparation, and be sure to include it in the class.

Preventing Lower Back Injuries in TwistsExcessive exion o the lumbar spine is also a risk in

seated twists, such as ardha matsyendrsana (hal lord-o-the-shes pose), and exion combined with rotation puts par-ticular orce on the spinal discs. Sitting with the hips up on aolded blanket can help the pelvis tilt orward, maintainingthe natural arch and length o the lumbar spine, even whileone leg olds in toward the chest.

As in the orward bend, a preparatory oor pose cangive support to the spine and prevent excessive exion. In

jathara parivartansana (revolved abdominal pose), or ex-ample, the student presses his or her shoulders into the oor,then twists the legs to the side, with the oor helping tomaintain length in the spine and evenness in the shoulders.

Props such as blocks or pillows can be used to preventinjury rom excessive eort in reclining twists, and to sup-port the student when the shoulders, arms, or legs cannotrest easily on the ground. In seated twists, the teacher shouldinstruct students not to use their arms to orce themselvesinto a more aggressive twist.

Preventing Lower-Back Injuries in BackbendsIn backbends such as ustrsana (camel pose) or rdhva

mukha svansana (upward-acing dog pose), injury to thelumbar area oten occurs because the thoracic spine does notbend, orcing the lumbar spine into overextension. Here, anoverzealous student may over-contract the lower back, goingor the outer shape o the pose without regard to techniqueor awareness. In many cases, it is up to the teacher to cre-ate this awareness in students. Student overzealousness inbackbends is oten a misunderstanding o how backbendsare to be practiced; many will assume that exploiting theexibility o the lower back is the intention o such poses.

Te ollowing instructions (or similar instructions, in thelanguage amiliar to a particular style or class) will help toprevent injury: Maintain steady strength in your legs, androot your tailbone down. Lit up through the whole upperbody and bend in the upper back as much as you can. Curlyour head, shoulders, and chest back. eachers also needa keen eye or asymmetries in students bodies that couldstress isolated parts o the spine.

Preparatory poses or active backbends include passivebackbends supported with props to encourage symmetri-cal length o the thoracic spine, bhujangsana (cobra pose)


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to practice the tailbone stabilization and active extensionin the thoracic spine, setu bandhsana (bridge pose) to si-multaneously strengthen and stretch the ront thighs and

increase thoracic and shoulder mobility. A preparatoryvariation oustrsana (camel pose) can also be practicedwith the arms or elbows reaching behind to the seat oachair instead o the eet.

Preventing Injuries in the Shoulders and WristsAdho mukha svansana (downward-acing dog pose),

chaturanga dandsana (our-limbed sta pose), and va-sisthsana (side plank pose), all poses that require bearingweight on the arms and hands, have been linked in oursurvey to injuries o the shoulders and wrists or hands.Many students will diligently try to achieve the ull pose

even without the technical instructions or strength requiredto do so saely. Again, the watchul eye o a teacher alertto over-eorting and poor alignment can make the dier-ence between learning and injury. When there is a rangeo abilities in a class, the teacher must accommodate andnot ignore those who cannot yet saely practice these poses,and provide alternatives in owing sequences such as sryanamaskar(sun salutation).

Te ollowing actions in these poses will reduce thechance o injury signicantly. First, spread the ngerso the hand or hands and press down evenly through allparts o the hand, avoiding passive weight-bearing on thewrist. Ten stabilize the arm or arms by contracting all armmuscles, pulling energetically up away rom the oor. Movethe upper arm(s) toward the back o the body, using theshoulder blade muscles o the upper back to position thehumeral head toward the back o the shoulder joint. urnthe upper arm(s) laterally as well, with the biceps musclerevolving orward. Ten expand the chest and lit the weighto the hands as much as possible by recruiting strength inthe torso muscles. Tese actions can all be practiced initiallyat a wall, or with the knees on the oor, to reduce weight-bearing while skills are developed.

Preventing Injuries in the Knees in Standing PosesTe knee is situated between the long bones o the upper

and lower leg, and shares muscles with both the hip jointsand ankle joints. Tis makes the knee dependent on thealignment and mobility o both the hips and ankles or itssaety. Wide-legged standing poses such as the vrabhadrsana(warrior pose) series put such a demand or stretch on the hipmuscles that the saety o the knees can be compromised.

Overzealous and uninormed students may attempt togo deeply into one o these standing poses, even i the orce

o the pose is being transmitted to the knees rather than toa healthy stretch in the hips. A narrower stance, which putsless demand on the hip and thigh muscles, is a saer way to

start. Other preparations could include using the support oa chair or the bent leg, or practicing near a wall.

A basic saety cue or students is to align the center othe knee with the center o the oot, i the knee is to theside, in ront, or in back o the heel. Encourage students toadjust their stance to reect the actual, not ideal, open-ing o their hips. Another saeguard is to use the musclesstrength evenly around the joints, avoiding the uneven pullsthat oten cause knee pain. o protect the ront legs kneerom hyper-extending in utthita trikonsana, press down themound o the big toe and do not lock the knee.

Preventing Injuries in the Knees in Other PosesPadmsana (lotus pose) is another example o a pose

that requires a great degree o exibility in the hip. I thehips are tight, students oten orce the pose by pulling theoot up with their hands, which puts tremendous dys-unctionalstress on the ligaments and tendons around theknees. Proper preparation might include standing poses andseated or reclining hip openers to gain mobility. Alternativeposes can be oered, such as baddha konsana (bound-anglepose), and sukhsana (easy pose) with props under the hips,knees, and possibly also under the shins.

o prevent overzealous students rom orcing the pose,the teacher needs to model and guide precise methods o en-tering these poses without suddenly or orceully pulling theoot and leg into the pose. Again, the teachers experience,training, and watchulness is essential; students commonlyneed eedback on this pose to understand whether they aresaely moving into the posture.

o prevent injury in virsana (heros pose) and eka pdarajakapotsana (one-legged king pigeon pose), a prop suchas a block or olded blanket under the hips will lessen thedemand or knee and hip exibility. People with previousknee injuries or surgeries should progress very careully to

gradually regain range o motion in these poses.

Summary o Recommendations

In summary, we oer several recommendations towardthe goal o greatly reducing the incidence o Yoga injuries:

1) eachers must be trained how to plan a sae Yoga practiceor the population o students at hand, using alternate ormso poses as needed.2) Studios and teachers can require a sel-assessment o each


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new students level o experience, strength, and exibility inorder to guide them toward an appropriate level o class.3) Students can be advised beore taking class that pre-ex-

isting conditions willaect their practice, and they can beencouraged to seek help in adapting the practice accordingto their needs.4) Te teacher and student must both know what consti-tutes appropriate levels o eort. Tis requires training orthe teacher and education or the students by the teacher.5) Te teacher must know how to spot overzealousness andalignment risks beore injuries occur.6) I classes are large, assistant teachers can help to watch oroverzealous and poorly aligned students.

Conclusions

Data rom this survey can be a useul starting pointor a urther investigation o injuries sustained doing Yoga,with the ultimate goal o education or both teachers andpractitioners. For this survey, no attempt was made to pre-screen respondents regarding their anatomical or medicalknowledge or to veriy the reports o injury. However, thestrengths o the resulting data lie in the number and widedistribution o the people involved, and the striking agree-ment in opinion across many styles as to both the causes oinjuries and areas o the body most vulnerable.

Tere is a signicant challenge inherent in this kind oinvestigation. eachers, therapists, and students oten havestrong allegiances to their style, their peer-group, their ownteachers, and their gurus. Tis may make them reluctant toreport or even acknowledge to themselves that certain inju-ries have occurred. Tis is the road to sel-deception, and todisguising harm rather than preventing it. Te therapeutic

Yoga community must have the courage and common senseto reely admit and actively examine the small amount oharm that is inadvertently done. Tis will allow us, as a com-

munity, to avoid ar greater harm to individuals and to thediscipline o Yoga itsel.

Direct correspondence to the authors at: Loren Fishman,[email protected], Ellen Saltonstall,[email protected], and Susan Genis, [email protected].

Reerences

1. American Academy o Orthpaedic Surgeons. ips toprevent yoga injuries. http://orthoino.aaos.org/topic.

cm?topic=A00063, March 14, 2007.2. DeBehnke DJ, Brady W. Vertebral artery dissection dueto minor neck trauma. Journal o Emergency Medicine. 1994Jan-Feb;12(1):27-31.3. Paul P. When Yoga Hurts. ime. 2007 Oct15;170(16):71.4. Kruco C. Insight rom Injury: I the practice o hathayoga was meant to heal, why are so many yogis getting hurt?Yoga Journal, June 2003, issue 174:120-124, 203.5. Kelly J. In Yoga, you can indeed try too hard. PittsburghPost-Gazette. Wednesday, December 06, 2006.6. Bertschinger DR, Mendrinos E, Dosso A. Yoga can bedangerous: glaucomatous visual eld deect worsening dueto postural Yoga. British Journal o Ophthalmology. 2007Oct;91(10):1413-4.9. Te Yoga Stra o Patnjali, ranslation and Commentaryby Swami Satchidananda. Buckingham, VA: Integral YogaPublications; 2004.

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