Body and Breath - Yoga Shop Talk

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Yoga shoptalk, April, 2003

Questions and Explanation, Paragraph One of six: Last August, nearly 7 months ago, I hurt my back playing tennis. I do not play regularly, it was early in the morning, and a two-handed backstroke did me in. At first, I did not realize I had hurt myself. At that time, I had a strong yoga practice and thought I was in excellent shape. Ha! After the tennis game, we sat at breakfast for a couple of hours with friends and when I stood up I was incredibly stiff!. The next morning I went to do yoga and tried to stretch out my lower back. I returned to the mat the second morning, and again the third, but by the third morning, I was in agony. I spent five days flat on my back (knees up) with ice, heat and excessive ibuprofen. I have used some acupuncture, regular massage, and a chiropractor gave me some exercises for the injured muscles which he named the iliocostalis and quadratus lumborum. There is also something more going on in my sacrum and psoas muscles, and I am concerned that this is a spinal cord or intervertebral disk injury.

Question, Paragraph Two: Since my injury I have tried various combinations of total rest with no yoga and no sitting practice for over a month. I have tried several consecutive weeks of practice. I quit going to class so that I was not trying to follow someone else's instructions and have done my own practice slowly at home, but then my back seems to worsen so I stop for a couple of more weeks. This seems to go on and on. I injured this same muscle twice before in my life many years ago. Once trying to hold up a large roll of snow fence that was tipping over and I was bent and twisted to recover it. Then again, same position with a posthole auger on the back of the tractor. Both times it took more than 6 months to heal but I was not doing yoga then.

Three: As I sit at the computer, the sensation is a mild, achy pulling in my sacrum and I feel as though I have menstrual cramps in my lower belly. The pain is across my sacrum below my waist and deep in my belly. The pain seems to originate on the left side of my twist/spin, above the waist. The pain is a pulling, taut, strained sensation. I have no radiating pain down my leg or anywhere else. It is solidly in the core of my body.

Four: During the day sometimes I make some move and have a sharp, shooting pain in the iliocostalis or quadratus lumborum muscles on my left side. I feel weak. Not systemically overall but weak because I am constantly compromised by the awareness of pain. I move with a new consideration. In the morning when I wake up, I cannot bend over to put on my sweat pants. I stand, hold a table, and step into them straight backed. I sleep on a new, fancy core-filled futon that seems helpful.

Five: On the yoga mat, I am able to do most everything if I take it slow and easy (except I would not attempt plow.) I can forward bend standing and sitting, twist, headstand, pigeon, backbend. Nothing "hurts" exactly but, things "tense and ache." The pain is some sort of sensation that suggests warming and stretching would help but actually, I get stiffer when I practice.

Six: Presently, I have taken another couple of weeks off after spending two weeks of daily yoga and then sitting for 30 minutes with a moist-heating pad on my lower back. I get up from this and I am stiff and sore. Sitting in a chair and curling forward triggers the sacrum stiffness. What I have not tried is just sitting practice without yoga first. I am perfectly comfortable in sitting practice while I sit. Sitting in a chair, however, is not as comfortable because I guess I am more rounded forward than when I sit cross-legged on a zafu. I have my annual gynecological exam the end of April. I thought I would ask her to order an MRI at that time to look at my spine. The pain is almost always present but I seem to be getting used to it . I don't think that is good. I don't want to further injury myself and I want to do something that will aid my healing. Do you have some ideas or advice?

Answers: Start by reading pages 151-159, 337-339, and the script on pages 207 and 272 in Anatomy of Hatha Yoga. This is to give you some background perspective on design problems of our bodies in relation to back problems. Also, please be aware that my comments here in this column are not to be construed as medical advice, for which there is no substitute, but that they are based on anatomical principles in combination with my own experience with back problems dating back 30 years. Then- Answering Paragraph One: Getting down to basics, injuries from twists such as you experienced during your two-handed back stroke are quite common. (As it happens, that was also my history, holding a heavy air conditioner, twisting, and then bending forward in my lumbar region to set the air conditioner on the floor.) I think your initial injury was probably limited to muscles and connective tissue tears, as was mine. Contrary to popular folklore, most disk damage occurs not from the initial injury but from excess back tension that bears down on the disks over a period of months and years. The stiffness you experienced is the starting point for this challenging state of affairs. So is it desirable to eliminate this stiffness? Not necessarily, at least not completely and not right away. The stiffness protects you from further acute tearing of the tissues, and the best strategy is to first encourage healing, then strengthening the muscles, and flexibility last. That is why massage (which is generally designed to relax the back) should be taken only in small doses if at all, and only after healing is well under way. For the moment relaxing should be done warily and solo. Most clinicians also recommend against heat until the injury is well past the acute phase. Cold packs for a few minutes several times a day are fine. The psoas, incidentally, is frequently imbalanced from a back injury incurred while twisting. What you are feeling in relation to the sacrum is probably sacroiliac sprain (meaning tearing of some of the sacroiliac supporting ligaments), especially if you are feeling it only on one side. You are probably overly alarmed about the possibility of spinal cord injury.

Answering Paragraph Two: I suggest avoiding hatha yoga for perhaps six months. Only mild abdominal exercises (chapter three) should be done. Standing, learn to adopt a mild posterior pelvic tilt (“tucking” the pelvis; “posterior” is in reference to the top of the pelvis), especially while lifting anything and while walking. The posterior pelvic tilt flattens the lumbar lordosis, which may be desirable for a long time. And have constant awareness of your breathing. As discussed in chapter three of Anatomy of Hatha Yoga, pressing down with the respiratory diaphragm, in with the abdominal muscles, and up with the pelvic diaphragm protects the back.

Three: Not (thankfully) being educated from experience about back pain from an early age, in contrast, for example, to awareness of touching something hot, often results in our not being able to locate the source of back pain precisely. And this reflects the vagueness of your symptoms. Just be aware that as healing and strengthening occurs, the symptoms will gradually subside. As to posture in general, you should avoid sitting altogether. Rather, set up your computer so the monitor is at eye level when you are standing. Then stand with a mild posterior pelvic tilt (gluteal muscles firm) and keep your knees slightly bent to keep your awareness on your base. And never sit in a soft chair. Avoid automobile trips that take longer than 10-15 minutes, and for short or requisite longer trips, try sitting with a board at your back. As to not having radiating pain, that is good, and is a fairly good indicator that sciatica is not involved.

Four: As to weakness, this is natural. Almost nothing depletes strength like pain, which is probably a good thing, since the pain protects us from further injury, much as not giving children aspirin for a fever keeps them from going prematurely back to enthusiastic play. For this reason, holistic practitioners do not recommend the use of painkillers in the routine treatment of back pain. Better to watch your activities carefully. Watch every movement, every posture. Washing dishes, stand with a tucked pelvis and exhale every time you reach forward. And focus your awareness on exhalation. Exhalation brings the abdominal muscles into play and protects you by increasing intra-abdominal pressure (see pages 157-159). Don’t even brush your teeth or pull open a drawer without constant awareness of breathing and of maintaining a posterior pelvic tilt. Get plenty of bed rest (a firm mattress is time-honored), which is helpful because that is the only time you can relax fully. Just be careful about how you get up.

Five: Drop it. You are kidding yourself if you are thinking these postures are helpful. If they were helpful, why would you get stiffer? Please stop now.

Six: Most medical experts now recommend cold rather than heat until back injuries are well on their way to healing. Heat in any form exacerbates new or recent injuries. In time, moist heat is good, although unnecessary in my opinion. As far as getting up stiff and sore after 30 minutes of sitting, why are you torturing yourself? There has got to be another way. You need at least a six months vacation from these practices. I remain skeptical of your sitting on the floor in any cross-legged posture. If you feel you must sit in a yoga posture for meditation, I suggest trying the adamantine posture on a tilted-forward bench (pages 575-578).

An MRI would be fine, but I would get it only for diagnostic purposes, favoring holistic advisors for treatment possibilities. Personally I favor chiropractors who are thoroughly trained in applied kinesiology or of one of its offshoots such as clinical kinesiology, but you will probably have to ask such practitioners explicitly for helpful exercise protocols. You should also touch bases with a physiatrist, if you can find one: the specialty of physical medicine and rehabilitation does not pay well, and therefore does not attract many trainees. Physiatrists, however, generally have more interest in therapeutic exercises than orthopedists, who are usually left at the starting block if they can’t recommend surgery, which, after all, is their stock in trade. A knowledgeable physical therapist can also be helpful for their knowledge of exercises for back problems, but I would be wary of their occasional penchant for wanting to relax you with ultrasound. Shop around. If you don’t feel certain that someone is helping you, they are probably not.

In my opinion one of the most important things you can do is to get used to regulating your activities so as to avoid pain, then gradually develop moderate mobility, then strength, and last of all flexibility. Think in terms of a ten-year plan; you must be an everlastingly patient patient. And no tennis until you are well. Surprisingly, if you master the skills discussed above, especially the knack of keeping your pelvis tucked and regulating your breathing, you can lift fairly heavy objects so long as you maintain awareness. You need to learn to watch yourself all the time. Stepping off a curb without awareness can set you back months. Once I stood in a drug store reading Newsweek, holding it half unconsciously out in front of me for 20 minutes, and I was in pain for two months afterward from the miniscule but continuing tension that aggravated my lower back. Oh, well. That’s karma. Life can be thought of as a series of decisions and of living with the attendant consequences. To my credit, I never did it again.

Another and perhaps the most helpful possibility: I think the best activity for aiding healing of back injuries is swimming, not, repeat not, the breast stroke or butterfly, but freestyle or the backstroke crawl, one or the other done properly. Get a coach to help you. If you do the freestyle, turn your head first one way and then the other for breathing. But even dog-paddling can help. As soon as you are largely free of pain, you can supplement swimming with supine posterior pelvic tilts, single leglifts, and abdominal exercises with your back held firmly against the floor. See chapter 3 and the cobras in chapter 5 (and page 323 for contraindications). As soon as you are mostly recovered, the postural habit of the posterior pelvic tilt will drop away of its own accord as you reinstate a traditional practice of hatha yoga. Good luck, and all the best to you.