Yoga Bones

SOURCES

THE YOGA THERAPY IN YOGA BONES

The therapeutic practices presented in this book draw from my work as an occupational therapist and yoga instructor, my understanding of using yoga as a therapeutic modality, and an exploration of my own body’s function and dysfunction. When working with patients, I think about yoga; and when I think about yoga, I think about healing the body and mind. For me, the two practices are inexorably linked and the efforts in this book draw equally from both mediums. The yoga therapy in Yoga Bones is grounded in this mutuality and joins occupational therapy approaches with the five-thousand-year-old practice of yoga. All of the following source material has contributed to the making of Yoga Bones. I have been a devoted practitioner of Iyengar Yoga since 1998, and many of the yoga strategies presented in this book draw from these studies and my ongoing practice. I have given myself flexibility in naming the postures that constitute a hybrid of yoga and traditional therapy.

ANATOMICAL

Most of the anatomical information presented in this book came from several textbooks I used as an occupational therapy student at NYU. The books I found myself returning to again and again are Clinically Oriented Anatomy, 5th ed., by Keith L. Moore and Arthur F. Dalley (Baltimore: Lippincott Williams & Wilkins, 2006) and Muscles: Testing and Function with Posture and Pain, 5th ed., by Florence Peterson Kendall, Elizabeth Kendall McCreary et al. (Baltimore: Lippincott Williams & Wilkins, 2005). Both of these books are quoted in the text of Yoga Bones. Over the years, and for this book, I also have read the work of Blandine Calais-Germain, Anatomy of Movement, rev. ed. (Seattle: Eastland Press, 2007). I also looked at Functional Anatomy of Yoga by David Keil (Chichester, England: Lotus Publishing, 2014). I have read countless academic journal articles and abstracts when trying to better understand the dimension of specific muscle function (such as the iliopsoas) or when there are conflicting perspectives about a particular condition (such as sciatica). I have tried to keep the information clear, accessible, lacking in bias, and grounded in function.

YOGA THERAPY

I intentionally kept my reading of other published yoga therapy and yoga books down to a minimum because I did not want to be overly influenced. I looked at Anatomy of Movement Exercises by Blandine Calais-Germain (Seattle: Eastland Press, 2018); Yoga for a Healthy Lower Back by Liz Owen and Holly Lebowitz Rossi (Boulder, CO: Shambhala Publications, 2013); The Vital Psoas Muscle: Connecting Physical, Emotional, and Spiritual Well-Being by Jo Ann Staugaard-Jones (Berkeley, CA: Lotus Publishing, 2012); B. K. S. Iyengar’s Light on Yoga, rev. ed. (New York: Schocken Books, 1979). I also drew on the coursework and studies from the professional yoga therapist training I completed in 2017 through Integrative Yoga Therapy, founded by Joseph and Lilian Le Page, and the teacher training Yoga for Low Back Pain presented by Loren Fishman, MD, in New York City in 2015.

OCCUPATIONAL THERAPY

My studies of occupational therapy started at NYU but have continued over the years. As professional development, I have taken yearly seminars and courses on subjects as diverse as complete shoulder rehabilitation, neurological management of spinal cord injury, therapeutic taping for posture and pain, bringing trauma-informed yoga into mental health practice, and functional movement techniques, to name just a few. I continue to learn daily from my patients and peers and work in several hospital units, including rehabilitation, acute care, and burns—all of which inform my learning and professional development.

FUNCTIONAL WELLNESS

These sections evolve from readings and studies in human development, pathology, cognition, neural plasticity, mindfulness, chakras, meditation, pranayama, and leisure. The leisure section quotes from American Journal of Recreation Therapy, Clinical Research & Practice for Illness, Aging & Other Debilitating Conditions 2, no. 1 (Winter 2003). B. K. S. Iyengar is quoted in “Functional Wellness: What Is It?”

Other source material includes Wherever You Go, There You Are by Jon Kabat-Zinn (New York: Hachette Books, 2005); Anatomy of Breathing by Blandine Calais-Germain (Seattle: Eastland Press, Inc., 2006); Light on Pranayama: The Yogic Art of Breathing by B. K. S. Iyengar (New York: Crossroad Publishing Co., 2002); Mudras for Healing and Transformation by Joseph and Lilian Le Page (Sebastopol, CA: Integrative Yoga Therapy, 2013); and Psychosocial Occupational Therapy: A Clinical Practice, 2nd ed., by Elizabeth Cara and Anne MacRae (Clifton Park, NY: Thomson Delmar Learning, 2005).

WHY YOGA BONES?

Millions of people suffer from orthopedic conditions that call for therapeutic interventions, ranging from chronic low-level discomfort to pain that stops you in your tracks. Over the years, I’ve observed that with physical and emotional discomfort, we subtly adjust our life around our deficit. If our knee hurts, we take the stairs less frequently. If our back hurts, it affects how we sit down and stand up. Sciatica and chronic knee pain are perfect examples of this. Sometimes, when recovering from an injury, it is essential to do this so as not to reinjure ourselves. Other times, discomfort eclipses previously enjoyable activities because they have become too difficult. Before we know it, our ongoing discomfort has limited our ability to fully participate in life. Yoga Bones offers condition-based yoga therapy for readers to design their own home practice, to heal pain, and to increase life engagement.

Yoga is a near-perfect medium for healing. Yoga helps people better understand their body limitations and provides tools to address them. It is a great practice during one’s rehabilitative process, while being equally effective in easing the chronic discomforts and tensions brought on by life. As an occupational therapist in a hospital, I’ve used yoga with patients one-on-one and in group classes to loosen joints, improve balance, and increase spinal flexibility—among other benefits. For those who wish to continue the rehabilitative yoga at home, injury-specific information is not always accessible. This is a shame, because yoga provides a road map for self-care during the fragile time of recovery, while encouraging a process of self-exploration through mindful movement practices. Addressing this need was the impetus for Yoga Bones.

Bridging the culture of medicine and yoga can be tricky. It is not uncommon for there to be lingering hostilities between traditional medicine and therapeutic yoga. I work equally in both environments and have as many conversations in defense of yoga as I have in defense of Western medical practices. Yoga Bones strives to close this divide. The chapters in this book are organized by orthopedic conditions to expand readers’ understanding and heal them through yoga. Yoga Bones includes Functional Wellness sections which contain mindfulness practices such as breathing, meditation, and chakra scanning, plus educational sections on the pelvic floor, anti-inflammatory nutrition, and more. This book can be used to prevent and manage lingering or active orthopedic pain and support an evolving mind-body connection.

HOW TO USE THIS BOOK

If you are diagnosed with a frozen shoulder, low back pain, or a herniated disc, ten chapters in this book address such conditions through yoga therapy. There are also three preventative chapters that focus on strengthening common problem areas, such as the core, the shoulders, and the knees. The chapters on the hands and feet are a hybrid of both—they help identify existing problems and modify outcomes of developing ones. The Functional Wellness sections provide perspectives, tips, and strategies on managing our emotional and energetic selves.

The chapters and sequences focus on the body structures related to each condition. Please take the time to read the short chapter introductions because they provide a deeper understanding of why you are doing what you are doing. This is important because knowing the reason(s) you are doing something is an essential component of any therapeutic intervention. Yoga Bones is written for use in a home environment, so common household furniture, such as walls, door frames, beds, chairs, countertops, and stairs are all in play. The yoga is demonstrated and described with different surface levels to make it adaptable for less-able-bodied individuals. If an asana causes distinct focal pain (not stretching pain), don’t do it or do it with less range.

It’s important here to mention that yoga therapy is not recommended if signs of an infection are evident, such as when skin is red or warm to the touch or if pain symptoms are severe or persistent. Instead, contact a licensed healthcare provider.

Have fun with your practice and be kind to your body!

PROPS

Yoga props are not required but help make the poses more accessible. The yoga props used in this book include a yoga mat, blocks, blankets, a belt, a bolster, and a backless yoga chair. Often props can be easily purchased online or in retail stores. Also remember that blankets, cushions, stairways, chairs, couches, beds, and other furniture in your home may be useful for you to experiment with. Backless yoga chairs are not required (though they are great!); a stable household chair will be perfectly fine. This picture includes the yoga props used for the book.

THE SPINE

CHAPTER 1: THE SPINE

Functional Wellness: What Is It?

CHAPTER ONE

THE SPINE

CURVES OF THE SPINE

The curves of the spine allow us to perform a vast number of movements with agility and support. Without spinal curves, it would be difficult to get things done. Activities such as commuting, walking, or getting off the floor require constant postural changes, and the four spinal curves allow for such adaptability. Imagine the difficulty of getting out of bed if the spine were as immovable as a piece of wood: the deep core postural muscles would be underutilized, and the limbs overutilized because they would have to initiate the awkward push into sitting. The spinal curves allow for shifts in body weight with relative ease and enable the head and trunk to fluidly stack on top of the pelvis. They allow humans to walk upright with straight legs and adapt more easily to the expansive demands of the environment. Curves allow for shock absorption, spinal rotation, and the ability to manage dramatic changes in body weight, such as pregnancy.

Each curve is a group of vertebrae that alternate between concave and convex. The spine consists of thirty-three vertebrae, with twenty-four of them above the sacrum. If you look at the body in profile, you will see that the neck is concave, the upper back is convex, the lower back is concave, and the sacrum convex. The sacrum is the bony wedge at the bottom of the spine that attaches to each pelvic bone to complete the pelvic ring. Below the sacrum are four tiny vertebrae called the tailbone, which are not traditionally considered a separate curve.

It is very important to have four distinct spinal curves and ideally the depth should be neither exaggerated nor flattened. The strength or weakness of surrounding muscles has a huge impact on the health of the curves. Generally, overly tight muscles can flatten a curve, and weak muscles can cause the curve to increase. Many back issues result from an imbalance of these curves because imbalance increases strain on the vertebrae, discs, and spinal nerves.

Two of the curves are primary curves and two are secondary curves. The two primary curves are the upper back and sacrum. They are primary curves because they are the same curve as an infant’s developing spine in utero—which is basically one long kyphotic seahorse-shaped curve. The lordotic curves of the neck and lower back evolve out of the initial kyphotic curve and are considered secondary curves. Movement is responsible for developing these secondary curves. The acts of breast- or bottle-feeding and prone (stomach) lying develop the neck and lower back curves. As functional movement begins to evolve, sitting unsupported, crawling, standing upright, and locomoting further develop secondary curves. Infants and children who have long-term chronic mobility issues often have poorly developed or almost absent spinal curves. Spinal curves are thought to be fully formed by age ten.

Many, if not all, professions contribute to imbalances in spinal curvature. Modern dancers often flatten their lumbar curves—whereas gymnasts tend toward increased curves. Overly tight abdominal and gluteal muscles can flatten a lumbar curve, as does a chronic posterior (tucked) pelvic tilt. Abundantly strong hip and leg muscles may increase a lumbar curve, as can long hours standing with knees locked backward into hyperextension. Think of almost any profession that has repetitive and static postural movements (surgeons, cashiers, therapists, office workers, dentists) and you will see affected spinal curves. The good news is that balancing strength between the extensors in the back of the body and the flexors in the front of the body provide dynamic support to maintain healthy curves.

LORDOTIC CERVICAL CURVE: SEVEN VERTEBRAE

The curve of the neck is concave. The thin bones of the seven vertebrae and the relatively thick discs provide for the neck to have the most range of motion in the whole spine. This degree of movement is important for humans to scan the environment, balance the head, and use their five senses.

KYPHOTIC THORACIC CURVE: TWELVE VERTEBRAE

The curve of the upper back is convex. The upper back is prone to “rounding” because it’s sandwiched between two mobile curves (neck and lower back) and because of the rib cage, which helps protect our heart and lungs. Additionally, respiratory issues, height, large breasts, and the weight of the head also contribute to an excessive curvature of the thoracic spine.

LORDOTIC LUMBAR CURVE: FIVE VERTEBRAE

The curve of the lower back is concave. The lower back has good capacity for flexion and extension due to the large size of the five vertebrae and thick discs. Though structurally strong, this portion of the spine is especially prone to injury because it supports the weight of the trunk and because the lower back compensates for faulty body mechanics.

KYPHOTIC SACRUM: FIVE FUSED VERTEBRAE

The curve of the sacrum is convex. The sacrum looks like a narrow horseshoe crab and is one large bone consisting of five naturally fused vertebrae. Like a keystone arch, the sacrum is sandwiched between the two pelvic bones and provides a strong base of support for the spine and pelvis. Once fused by age eighteen, the five bones of the sacrum have no movement between them—though there remains limited movement in the two large sacroiliac joints connecting the sacrum to the pelvis. The sacroiliac joints distribute weight from the spine into the pelvis and legs.

THE COCCYX: FOUR “SEMIFUSED” VERTEBRAE

The tailbone evolves early (fourth to eighth week) in embryonic development. The small curve of the coccyx is continuous with the curve of the sacrum and has minimal ability for flexion and extension. The coccyx provides attachments for parts of the gluteus maximus and many muscles of the pelvic floor.

STRUCTURES OF THE SPINE

The spine is a flexible axis of bone and soft tissue in the center of the body. There are thirty-three vertebrae, twenty-four of them above the sacrum. Each vertebra has a bony ring that envelops and protects the spinal cord. The first three spinal regions are named and numbered according to their location in the spine, and each starts with the number one. For example, the cervical vertebrae in the neck are C1–C7, the thoracic vertebrae are T1–T12, and the lumbar vertebrae are L1–L5. The sacrum and coccyx are named—not numbered, and the first two cervical vertebrae are called the atlas and axis.

The vertebrae become larger as they move down the spine, and are connected and cushioned by the intervertebral discs between them. Facet joints link each vertebra to its adjacent one, which ensures articulate gliding movement between the bones. Often, when people have arthritis in their spine, it is the facet joints that have become stiff. A firm, broad ligament called the anterior longitudinal ligament attaches along the length of the front of the spine and limits extreme back bending (hyperextension). The narrow and weaker posterior longitudinal ligament is in the back of the spinal column and prevents extreme forward bending (hyperflexion). It also helps the discs from herniating backward into the spinal nerves.

SIX ACTIONS

The spine also provides bony attachments for deep postural muscles. These muscles help move the spine in six distinct actions: forward bending (flexion), back bending (extension), side bending (lateral flexion), and twisting (rotation) to the right and left. The lower back has good range of motion for flexion, extension, and side bending. The rib cage has better (potential) range of motion for rotation than for flexion and extension, and the neck moves in all directions.

THE VERTEBRAE

Although they each have a unique shape, twenty-two (of twenty-four) vertebrae share similar structural characteristics. If bone density diminishes, the top and bottom surface of each vertebrae can become concave, which partially accounts for age-related changes in height. The drawing is of the lumbar vertebrae.

1 vertebral body

2 transverse processes

1 posterior spinous process

2 laminae (arms)

2 pedicles (feet)

2 facet joints (which attach to the vertebrae above and below)

1 vertebral foramen (where the spinal cord travels)

THE ATLAS AND THE AXIS

The atlas and the axis (C1 and C2) are the first two vertebrae in the human body and distinct from the other vertebrae. The base of the skull (occipital bone) sits on the two large facet joints of the atlas. The movements of this atlanto-occipital joint are the movements of flexion and extension, as when saying yes, and lateral bending. The second cervical vertebra, called the axis, has a small protrusion of bone called a dens, upon which the atlas pivots. The movement of this atlanto-axial joint is the movement of the head saying no. There is no disc between the atlas and axis.

THE SACRUM AND THE COCCYX

The sacrum comprises vertebrae 25–29 that form a large, immovable triangle sandwiched between the bones of the pelvis. The coccyx is the “tail” end of the spine and accounts for the vertebrae 30–33, and is all the way down near the bottom of the buttocks. The sacrum itself is an unmovable bone, and movements of the sacroiliac joints (where the sacrum attaches to the pelvic bones) are also quite limited—documented between 1/16 and 1/8 of an inch. However, sacral joint movements do occur during childbirth, and often with individuals who use their body professionally, such as dancers, yogis, athletes, and gymnasts. There are no discs in the sacrum and coccyx.

THE DISCS

The intervertebral discs account for 20 to 25 percent of the height of the spine. Discs are thicker in the neck and lower back region. Discs have two main components: a fibrous outer ring called an annulus fibrosus and a gelatinous interior mass called the nucleus pulposus. The nucleus is about 88 percent water, but with age loses hydration, causing the disc to become firmer, flatter, and less flexible. Degeneration of the discs can be another factor in height loss. The last disc is between L5 and S1.

THE NERVES

The central nervous system (CNS) comprises the brain and spinal cord. Once the nerves exit the spinal cord and/or brain stem, they are considered peripheral nerves. Peripheral nerves provide information to and from the brain to the rest of the body. Peripheral nerves include twelve pairs of cranial nerves and thirty-one pairs of spinal nerves. Of the spinal nerves, there are eight pairs in the neck, twelve in the rib cage, five in the lower back, five in the sacrum, and two in the coccyx. The spinal nerves contain two rootlets that provide sensory and motor function to the rest of the body.

The spinal cord is shorter than we think, ending where the lumbar spine begins and the rib cage ends. At this point, the spinal cord turns into a long bundle of nerves and nerve roots called the cauda equina (which means “horsetail” in Latin). This collection of nerves continues down through the lumbar spine, sacrum, and coccyx and exits into the pelvis and legs. This is why when you have a lumbar spine nerve issue, you feel it in your lower body.

A LITTLE MORE ABOUT OUR PERIPHERAL NERVOUS SYSTEM

The body cleverly subdivided the peripheral nervous system into two parts: the somatic (body) nervous system (SNS) and the autonomic (self-governing) nervous system (ANS). The somatic nervous system describes the part of our nervous system that helps us control our skeletal muscles and is under our conscious control. If we feel like bending our elbow, the SNS allows us to perform that action. If we get a massage, our body’s sensory receptors tell our brain to relax those muscles. Yoga asana practice elicits a lot of sensory and muscular feedback from the somatic branch of the peripheral nervous system, and that is one reason yoga practice can be so relaxing.

On the opposite spectrum, the autonomic nervous system connects to the inner body. This branch of the nervous system is a self (auto) regulating process and affects the hormonal output and function of the glands, organs, and smooth muscle (e.g., intestines, blood vessels). The ANS is particularly responsive to strong emotions, such as joy, fear, and stress, which in turn affect the hormones produced by these glands and organs. The ANS has a “fight or flight” response and a “rest and digest” response. The “fight or flight” response is governed by the sympathetic branch of this nervous system and alerted when we are stressed out, scared, and panicked. For instance, this response would be activated if you were walking alone at night and felt you were being followed. It would provide your body with the adrenaline to run and for your pupils to dilate to see where you were running. The “rest and digest” response is governed by the parasympathetic branch of this nervous system. This response is heightened when we are resting and feel safe. It acts as a kind of brake to the sympathetic response by releasing hormones, such as dopamine and acetylcholine, which expand the airways, relax digestion, and help us feel connected to one another.

Both the sympathetic and parasympathetic systems control healthy adaptive responses important for survival, and both act on the same glands and organs but elicit different chemical responses and physiological reactions. Because humans are a stressed-out species, a case can be made for needing to downregulate our sympathetic response to allow for more of our parasympathetic response to flood the body with stress-relieving hormones and neurotransmitters. This is especially true if you tend to be a high-stress person or live a high-stress lifestyle. Yoga is effective for stress reduction and reducing blood pressure in part because it acts on the parasympathetic branch of the nervous system through slow, steady breathing, stretching, and restorative yoga postures.

THE LOWER BACK

CHAPTER 2: LUMBAR HERNIATIONS

Functional Wellness: Your Practice Space

CHAPTER 3: SCIATICA

Functional Wellness: Feel Your Body!

CHAPTER 4: SPONDYLOLISTHESIS

Functional Wellness: Chakras and the Life Span

CHAPTER 5: LOWER BACK PAIN (AND YOUR ILIOPSOAS!)

Functional Wellness: Chakras

CHAPTER 6: CORE STRENGTH

Functional Wellness: The Pelvic Floor

CHAPTER TWO

LUMBAR HERNIATIONS

If you imagine a raspberry jelly donut, you will have an idea of the mechanics of a herniation. The thick outer ring of a disc (annulus fibrosus) is made from firm elastic cartilage, and inside is a gelatinous center (nucleus pulposus) with the consistency of thick jelly or crabmeat. Forceful spinal flexion pushes the nucleus backward into the outer ring to the point where the disc wall breaches and the inside contents leak out. When this happens, disc material comes in contact with the nerve roots, causing pain and muscle weakness below the level of the injury. A herniated disc is sometimes referred to as a “ruptured” or “slipped” disc. The most common sports involved in disc herniations are bowling, tennis, running, football, hockey, weight lifting, and gymnastics.

A healthy disc absorbs an impact, such as carrying a heavy child or backpack, by bulging outward in all directions and then returning to its proper shape. A bulging disc occurs when a part of the disc becomes protruded and stays that way—like a water balloon being squeezed. Bulges can impact spinal nerves and are prone to becoming herniations. Disc bulges and herniations also occur from accidents, cancer, surgeries, or discs’ degenerating with age.

Lumbar discs are plump, about one-quarter the width of the vertebral body, and one of their main functions is to absorb shock and allow for spinal flexibility. Herniations are often a result of forward flexion and flexion with rotation, such as when you bend over to pick up something heavy that’s near your ankle. When the discs are injured, it can cause severe reflexive muscle spasms in the lower back and buttocks, and the nervous system rushes in to immobilize the area (this is often why people can’t move or stand up after they herniate their discs). Ninety percent of lumbar herniations occur in the last two vertebrae.