Asana Analysis: Hero/Virasana

Hero/Virasana
Last week’s post was Triang, in which one leg is tucked back. That tucked back position could be considered ‘virasana-style’. In Hero pose, both legs are tucked back with the knees together and the hips resting between the feet. Some consider this seated posture a good one for meditation however I wouldn’t recommend sitting in this pose for more than 5 minutes, especially for us westerners who spend so much time in chairs. It is a good posture to hold for a minute or two though, to help keep our hips, knees and ankles flexible and healthy.

Muscles Stretched: Quads (including rectus femoris), anterior tibialis, flexor digitorum longus, flexor hallicus longus

Points of Body Awareness:
*Roll the calves outward to optimize alignment of the knees before sitting.
*Do you feel rooted to the earth? The sit bones should be firmly and equally in contact with the ground.
*Is your spine in a neutral position? There should be a small, inward curve in the lower back, a small outward curve between the shoulder blades and a small inward curve at the neck.
*The legs and feet may feel uncomfortable but you should not have any pain in the knees.
*Can you be content in spite of some discomfort in the feet? Can you keep the jaw and facial muscles relaxed? Can you focus on steady, even breathing? If not, modify the pose and try again

To Modify: Sit up on a block or bolster to decrease the amount of knee flexion or to allow for more length through the spine. If there is unbearable discomfort in front of the ankle, try a small, rolled towel in front of the ankle. If the top of the foot is very tender, double the mat under the foot to provide more padding.

PT Notes: This posture can be used as a side-to-side comparison of ankle plantar flexion ROM or anterior compartment flexibility. (I did this myself after a bad foot injury, though I confess I started it too early). Once a patient has achieved full and painless ROM as measured by goniometry, check tolerance for a weight-bearing stretch in Child’s Pose. If this feels okay, then progress to Hero sitting upright. Observe the posture of the patient in the coronal plane. Is there a lateral tilt in the pelvis or any lateral curvature in the spine? Ask the patient if they feel equally weighted or if there is any subjective difference in position or sensation between injured and uninjured sides.

See 3-Angle Forward Bend regarding the use of this posture in patients with a history of knee injuries.

See Yoga Journal for more detail.

Is Generosity Always Good?

Last weekend I saw the movie, Please Give. I didn’t love it. But I did find it intriguing. The acting was good, the characters were unique. It had amusing moments that made me chuckle and a few scenes that made me cringe. (Not the least of which was the opening scene). But I left the theater thinking, “and the moral of the story is?”

Without giving too much away, the movie is centered around themes of discontent, compassion vs. self-preservation and generosity (sometimes misdirected, sometimes lacking) toward our families, neighbors and fellow human beings.

Feeling discontentment is an all-too-human experience. Whether or not a person is initially drawn to yoga for it’s moral and emotional benefits, most of us eventually find some degree of comfort in the yamas and niyamas. We find an element of peace in the unity and grace that the philosophy of yoga offers.

But the characters in this movie didn’t appear to have any spiritual insight. There were no philosophical inquiries into the roots of their suffering. Instead each character succumbed to an act, behavior or an attitude that reflected and perhaps magnified their suffering. But the interesting thing about the movie for me, was that I couldn’t decide if I liked the characters or not. They all had weaknesses. Most were mean, petulant, rude, selfish or pathetic at some point. But at the same time, it was easy to see their vulnerabilities. It was easy to see their humanness

The movie ended in way that I found unsatisfying. But I also felt a sense of empathy toward the characters, for I think that we’re meant to recognize something of ourselves or our loved ones in them. But overall the movie left me with more questions than answers. What is generosity? Does being charitable always make us happy? Does it make a difference what we give or to whom we give? Why do some people feel guilty about being profitable while others do not? Can we be too generous? Can we give too much? Why are $200 jeans so important?

If you’ve seen the movie, I’d love to know what you thought of it. Even if you haven’t seen the movie, I want to know your thoughts on generosity, compassion and happiness.

Asana Analysis: 3-Angle Forward Bend/Triang Mukhaikapada Paschimottanasana:

3-Angle Forward Bend/Triang Mukhaikapada Paschimottanasana:
This is a posture that I personally like despite the fact that it looks like this posture should be really ‘bad’ for the knees. Even before I went to PT school, I learned to outlaw the classic, “hurdler’s stretch” with one leg tucked back. I learned that this position could over-stretch the ligaments and injure the knee. But in recent years, I’ve begun to rethink this classic wisdom. Is there really a good reason to avoid end-range knee flexion in a healthy knee? Let’s think about the mechanics of the knee. The knee is not really a simple hinge joint. In order to obtain full knee flexion, the tibia (lower leg bone) must essentially internally rotate with respect to the knee. This internal rotation of the tibia is what differentiates the the classic ‘hurdler’s stretch‘ from the triang posture.

Muscles Stretched: Hamstrings, gluteus maximus, quadriceps, tibialis anterior, flexor digitorum longus, flexor hallicus longus,

Points of Body Awareness:
*Roll the calf of the bent knee outward before lowering the hips to the ground.
*Both sit bones (ischial tuberosities) should be in contact with the ground. Your pelvis should be level and the weight equally distributed.
*Can you differentiate between pain and intense stretching in the knee? If it feels sharp or shooting then it is too much and you should back off. If you feel discomfort on the outer or inner sides of the center of your knee, then you should most likely back off. Do you feel a really strong sensation just above your knee cap or in the front of your shin? If so, this is likely a good stretch.
*Once you’ve established a good seated foundation with an appropriate stretch in the bent leg, turn the navel toward the extended leg, lengthen the spine, and fold forward.
*Can you continue to feel length through the spine?
*Can you focus on letting go with each slow, deep breath?
*Hold the posture for 6 to 10 breath cycles then come out of the pose slowly. First lift the torso back up, then lean toward the extended leg and use your hand to gently guide the bent knee back to an extended position.
*Can you feel a sense of increased circulation/lubrication/energy around the knee that was bent?
*Take a moment to feel the effects of the pose before moving on to the other side.

To Modify: Sitting up on a block or bolster will decrease the amount of knee flexion range. It will also allow for more extension through the lumbar spine during the forward bend over the extended leg.

If the knee feels okay but the buttock on the side of the bent leg does not reach the ground, try placing a folded blanket under the the sit bone of the extended leg. Adjust the height until the pelvis is level and both sit bones are grounded.

If there is unbearable discomfort in front of the ankle, try a small, rolled towel in front of the ankle. If the top of the foot is tender, double the mat under the foot to provide more padding.

PT Notes: Although I often do this pose myself, it’s not one that I’ve often taught to patients. I think you would need to be very cautious if your patient has had a knee injury. However I do think this could be a therapeutic pose if done properly, for a patient with an old injury (greater than 6 months) that is still a slow, remodeling phase. I would assess and treat any restrictions of the patient’s posterior glide of the medial tibial condyle and anterior glide of the lateral before attempting this pose. As with any yoga posture, the most vulnerable aspect of the pose is transitioning into and out of the the posture.

This pose can be beneficial for patients with shin splints or tightness of the anterior compartment of the leg. Child’s pose would be a good posture to start with, progressing to triang as tolerated.

A variation often suggested as an alternative to the ‘hurdler’s stretch’ is to tuck the heel into the groin. But this really isn’t comparable. The hip is externally rotated instead of of internally rotated. Doing a forward bend with the hip in internal rotation provides it’s own unique challenge and sport-specific ROM. Combining flexion with internal rotation compresses the ball-and-socket joint. This might aggravate an arthritic hip but compression is necessary for healthy joints. Compression is the mechanism by which the articular cartilage is nourished and it’s wastes removed. By habitually avoiding a particular range, we may be doing more harm than good. A combined flexion/internal rotation motion occurs during cycling, kicking, dancing, and pivoting/cutting motions. A loss of range in the hip can surely result in increased compensation in the more mobile/less stable knee.

So while the old-fashioned hurlder’s stretch with the foot cocked out to the side is one best left to the history books, triang is good alternative that allows full ROM through the joints without unnecessary stress on the ligaments of the knee.

See yoga.com for more details on this posture.

10 Yoga Poses for Soccer Players

My last post was all about the World Cup and the amazing athleticism of it’s athletes. Given the amount of running, sprinting and kicking that soccer players do, most of them would benefit from an asana program that emphasizes improving flexibility of the legs. John Gallucci Jr, PT, is the medical coordinator for Major League Soccer and in the current issue of PT in Motion magazine, he says "Usually soccer players have very, very tight adductors and tight hip flexors. One of our most important goals in the league is to improve players' flexibility in those two areas. We believe that if we can get more elasticity in the tissues, we can prevent more of the groin and hip injuries that are common to these athletes."

But not only do soccer players tend to have tight muscles, they can also have significant asymmetries as explained by Ara Uebelhor Knepp, PT, DPT, CSCS in the same article. "Soccer is a lopsided sport. Most of the guys are 80% one leg dominant. So most of the time they are kicking with one leg and planting with the other," Knepp says. "They use their hip flexor and quads on one leg and a lot of glutes and hamstring on the planting leg. This causes many issues with both the hip and the spine."

The following yoga postures will improve flexibility of the leg muscles, especially the hip flexors and hamstrings:
1. Down Dog
2. High Lunge
3. Warrior II
4. Warrior I
5.Warrior III
Hold each Lunge or Warrior pose with the dominant leg back, stretching the hip flexors for about 6 slow, steady breaths. (This should be equivalent to at least 30 seconds). When the dominant leg is forward, hold for about 3 breaths (at least 15 seconds). There are several variations that can enhance the the above poses. For example, High Lunge with a Twist: place the opposite elbow on the forward knee, palms together and open the heart toward the side of the forward leg. Such variations provide multi-planar motion, critical for pivoting/cutting sports like soccer.

6. Seated Straddle: This is great stretch for the inner thigh muscles. Most athletes with tight hamstrings will need to sit on the edge of folded blankets or towels in order to keep the back strait.

7. Gate Pose: This is a good pose for the hamstrings and adductors of the extended leg and the quadratus lumborum on the kneeling side.

8. Hand-Foot/3-Way Strap Pose: For this posture, hold the planting leg (non-dominant side) forward/up for 6 breaths and the dominant side for 3 breaths. This pose can also be done in a standing position, which is a challenging pose, requiring strength, flexibility and balance... great for any athlete!

9. Pigeon: This posture stretches the outer hip of the front leg and the hip flexors of the back leg. Again, if the hip flexors and quads are tighter in the dominant leg, spend more time with that leg extended back.

In addition to improving flexibility, yoga can also be restorative. Doing relaxed, supported postures is a great way to allow the body to recover from the intense workouts of both professional and recreational players. All yoga sessions for athletes should include at least one long, restorative posture. During peak training or competitive periods, a whole session of nothing but restorative yoga can help the body recover from workouts and to stay healthy and injury-free. A favorite restorative pose for releasing the inner thighs:
10. Reclined Butterfly

These are postures that can benefit anyone, from a professional soccer player to a sedentary couch potato (especially one busy rooting for the pros). If you are new to yoga, get a skilled teacher to instruct you in order to make the most of your experience. And if you are injured, see a physical therapist who can evaluate and guide you toward the safest and most effective stretches.

Go team!

Watching the World Cup

The World Cup is underway. I am fascinated by the divide between those who watch this international sporting sensation and those who, like me, are pretty much oblivious. Although I played soccer as a child until I was 16, I really knew nothing about it as a spectator sport. I had some vague knowledge that it was popular in many other parts of the world but I couldn’t even keep up with the big three in Cleveland: football, baseball and baketball. So the idea of taking on another sport to watch was never particularly appealing. Now I am married to someone who loves to watch every minute of every game. So yesterday we went to a local movie theater to watch the USA vs. England game and I have to say that it was actually a lot of fun to watch with a vocal, passionate group of fans (including the few, rowdy English fans). I’m starting to get the attraction. Like the Olympics, it is a fun and healthy way to express national pride. It’s a colorful display of countries throughout the world presenting their best (and sometimes worst) examples of style and sportsmanship. And like March Madness or the lead up to the World Series, it’s fun to pick a favorite few teams and cheer them on throughout the month.

Perhaps most impressive is the shear athleticism of the players. The level of fitness required to play this sport is immense. They must have excellent endurance, stamina, power and coordination. A player will typically cover over 6 miles per game, walking, running and sprinting with a heart rate at 80-90% of their maximum for two 45-minute halves. Injuries are common, especially sprains, strains and fractures in the ankles, knees or hips. Some injuries are simply the result collisions that are inevitable in this fast-paced and aggressive sport. But other injuries such as groin strains, hamstring tears and Achilles tendonitis can be the result of unbalanced muscle groups, poor flexibility, or lack of willingness to rest and recover. There are many physical therapists out there who are knowledgeable and skilled at helping players to sort out these issues and to recover from such injuries. But of course, I would advocate yoga as a means to prevent those injuries from occurring in the first place. By improving body awareness and flexibility, and by practicing methods of deep relaxation, overuse injuries will be less likely to occur. One team that has taken this to heart is the men’s soccer team at Dartmouth. Also, Manchester United’s Roy Keane has touted the benefits of yoga. Later this week, I’ll post some ideas about some yoga postures that are particularly useful for soccer players.

Asana Analysis: Extended Puppy Pose

Extended Puppy Pose:
Puppy pose can be a useful variation of down dog. However, I decided to include this posture as a separate pose rather than just a modification of down dog because it can serve as training ground for down dog but it can also stand on it’s own as a posture for lengthening the spine, stretching the shoulders and providing a gentle and quieting inversion.

Muscles Strengthened: Wrist and finger flexors, triceps, infraspinatus, teres minor, supraspinatus, serratus anterior, transverse abdominus

Muscles Stretched: Latissimus dorsi, teres major, posterior deltoid, rectus abdominus

Points of Body Awareness:
*Keep hips in lined up over the knees, with the femur bones in a vertical line.
*Keep the arms active, much like you would in down dog. Stretch through the fingers and hands. Feel the muscles in the front of the forearms engaging. The elbows are lifting up, off of the ground and the upper arms are rolling inward toward your ears (actually glenohumeral external rotation).
*Roll the sit bones (ischial tuberosities) up toward the ceiling. This should be much easier to to here compared to the same action in down dog. Because the knees are bent, there is much more slack in the hamstrings and freedom of motion in the pelvis.
*Can you feel a sense of lengthening in your spine? Imagine the lumbar spine is just hanging from the pelvis and sacrum. Let gravity work to lengthen your lower back.

To Modify: You can use a blanket or block under the forehead to decrease the amount of inversion and support the neck. You can also use a bolster under the chest for a more restful version of the pose.

To Challenge: You can increase the stretch of the lats by placing the palms together and bending the elbows so the palms move toward the back of the head.

PT Notes: This a a great pose to use for providing manual traction to the lumbar spine. You simply stand in front of the patient and press their sacrum away from the lumbar spine. You can step lightly onto their hands (shoeless of course) to help stabilize their upper body. If this is appropriate for your patient, you can teach a partner or family member of theirs to provide the traction. Do be mindful of body mechanics though, as it requires quite a bit of flexibility on the part of the adjuster to reach the sacrum.

Puppy pose is very useful as an alternative to child’s pose if end-range hip, knee, or spinal flexion is painful or contraindicated. For example, if a patient with an unstable HNP or who is a few months post-op for THA or meniscal repair takes a group class, I would instruct them to use this posture whenever the teacher instructs the class to rest in child’s pose.

See Yoga Journal for more information.

#10 of Asana Analysis series

The 21.5.800 Challenge

Yesterday I happened upon this challenge presented by blogger, Bindu Wiles: for 21 days, do yoga five days a week and write 800 words per day. I've been feeling the need for a little bit more discipline and structure in my life so I signed on. I later found out that 800 words is equivalent to four or five pages! I have no idea what I'm going to write about or how I can possibly write that much every day for three solid weeks, but I am intrigued by the challenge. But don't worry, I'm not going to post everything I write... only the good stuff. (Hopefully there will be some good stuff.)

So to acknowledge the start of this new challenge, I want to share another niyama or yogic observation. Tapas means heat in Sanskrit. It refers to discipline and austerity, a necessary trait to achieve all our goals, spiritual or otherwise. Here is an affirmation from Kripalu about Tapas:

I cultivate discipline. I have a realistic and balanced schedule for my seva(service), sadhana(spiritual practice) and personal needs. I am disciplined and also relaxed. I do not drain my energy by over effort and overwork. My purpose is clear, my mind is decisive.

That's about 200 words, bringing my total for the day to about 550. Not a bad start...

Aha... I knew it! Evidence to support the validity of acupuncture.

I admit there is a lack of rigorous scientific evidence to support alternative therapies such as yoga and acupuncture. But I’ve often felt that this might be because we don’t have the means to study subtle, energetic effects of healing. Or the more likely reason is because we don’t have millions of dollars going toward studying these therapies as no one stands to make millions of dollars by patenting them.

While I am all for an evidenced-based approach to health care,I’ve always felt that many alternative strategies for pain relief and wellness are valid and useful complements to physical therapy. Obviously I believe that yoga and meditation are powerful tools for healing. But there are also a lot of other alternative therapies out there including Alexander technique, homeopathy, craniosacral therapy, aromatherapy, etc., etc. Among the many possible alternatives, acupuncture seems to be one of the most effective but yet also one of the more mysterious methods. The placement of needles in specific points of the body supposedly unblocks ‘qi’ or life force so it can flow within invisible channels of energy called meridians. Hmm. That’s a hard nut to crack for a scientist.

But an article in Wall Street Journal this week reports that recent research has revealed that acupuncture seems to work by increasing the amount of a molecule called adenosine in the tissue around the needle. Adenosine is a molecule that is critical for many biochemical processes within the body, including energy transfer (it’s a component of ATP... anyone remember the dreaded Kreb’s cycle?), inhibition of the central nervous system, sleep promotion and it has strong anti-inflammatory qualities. The research states that the level of adenosine increases by 24 times! It seems the conclusion is that acupuncture works by causing a very real and powerful anti-inflammatory effect. I’m sure that this is true but I think that one must consider the other actions of adenosine as well. Having experienced acupuncture many times myself, I can vouch for it’s inhibitory and sleep-promoting qualities. As far as it’s role in energy transfer is concerned, it makes me wonder if there is something to those meridian pathways after all.

So it looks more and more like the needles do have a true physiological effect. But a good practitioner of acupuncture doesn’t just use needles. They also council their patient on diet,exercise and lifestyle. So maybe the increased adenosine helps to temporarily relieve symptoms of pain (just as a drug, a massage or an ice pack would) but the advice such as cutting sugar out of the diet and to doing gentle, rhythmic exercises will keep the pain from coming back. This holistic attitude is one that all western health care professionals should understand and prescribe.

Asana Analysis: Down Dog/Adho Mukha Svanasana:

Down Dog/Adho Mukha Svanasana:
This iconic pose is done in almost any hatha yoga class. It captures the essence of yoga in that it combines strength and flexibility, intensity and inner focus.

Muscles Strengthened: Wrist and finger flexors, triceps, infraspinatis, teres minor, supraspinatus, serratus anterior, transverse abdominus, lumbar extensor muscles, iliacus, psoas, adductor magnus, quadriceps,

Muscles Stretched: Latissimus dorsi, teres major, hamstrings, gastrocnemius, soleus

Contraindications/Precautions: Inversions like down dog, with the head below the heart, are contraindicated for those with detached retina, glaucoma, and high blood pressure. It is also not recommended for those who are menstruating or have a head cold or sinus infection.

Points of Body Awareness:
*Be sure to root the hands into the ground. The middle fingers point strait ahead and the thumbs stretch in toward each other.
*Is the knuckle of the index finger grounded? It should be. Most people tend to roll towards the outer side of the hand, allowing the first knuckle to pop up, off of the ground. Be sure to keep the weight evenly distributed across the hand.
*Can you feel the muscles on the front of the forearms working? These muscles flex the wrist and will help you to keep more weight in the front of the hand and less on the heel of the hand (which compresses the carpal tunnel).
*Make sure the elbows are not hyperextending.
*The upper arms should roll in toward your ears. This will help to keep your shoulder joints in good alignment. (This rolling in action is actually external rotation of the humeral head which is accomplished by the rotator cuff muscles.)
*Is your thoracic spine in a neutral position? There should be a slight outer curve of the spine between the shoulder blades. Flexible people tend to hang through the shoulders, resulting in hyperextension though the thoracic spine.
*Where is your gaze? It should be at the tops of your thighs.
*Can you roll your sit bones (ischial tuberosities) up toward the ceiling? If so, your lumbar spine will form more of an inward curve, closer to a neutral spine position.
*Can you feel a sense of length in the entire spine, through the shoulders, forearms and into the ground? Establish this length first, before trying to straiten the knees or ground the heels.
*Can you straiten the knees without losing the upward rotation of the sit bones? Tight hamstrings will pull the sit bones back down, rounding the lower back. It’s better to work on stretching the hamstrings with a different posture instead of stretching with a rounded back in down dog.
*Ground the heels evenly. Can you feel a sense of energy moving from the ground up through the legs?
*Breath with slow, steady breaths. Inhale and exhale through the nose.

To Modify:

A good alternative for beginners, people with shoulder or elbow injuries or those head colds, high blood pressure or other contraindications is ‘down dog on the wall.’ Instead of bearing weight through the arms on the ground, the arms are placed on a wall with the torso forming a 90 degree angle with the legs. (Note, this requires greater wrist extension range so it may be difficult but perhaps therapeutic for those with wrist injuries.) This is a good way to practice proper alignment of shoulders and spine. This will also be a good stretch for those with tight hamstrings or lats.

If the wrists are healthy but too stiff or sore in regular down dog, you can place a wedge or small rolled-up towel under the heels of the hands to distribute the weight more evenly.

For a slightly more restful variation, rest the forehead on a block or bolster.

To Challenge: Lift one leg. Keep the pelvic girdle level in order to develop more strength of core muscles including gluteals and obliques. Or allow the pelvis to rotate and the lifted leg to cross over midline for a fun, inverted twist. Lifting one leg with a level pelvic girdle level is also an excellent strength-building exercise to do with the wall variation described above. (Although at this point it looks more like Warrior III than Down Dog.)

PT Notes: It is critical to assess patients in this posture if they plan to return to a community-based yoga class as it is almost certain they will be doing down dog. Assuming the patient can bear weight through their arms, I usually introduce the concepts of finding neutral spine position and proper weight bearing through the hands with the patient in quadraped. Then progress to the ‘down dog on the wall’ as described in modifications. This requires the patient to practice those body awareness skills while stretching the shoulders and hamstrings but without yet having to bear weight though the arms. The next step is to try extending one leg. This requires a fairly high degree of core stability and body awareness. Once the patient can do this without any pain or compensations, then assess the traditional down dog posture.

Another way to use down dog therapeutically is to provide traction while in the pose. One way to do this is to hang from a pole or a strong bar while in the ‘down dog on the wall’ position. Another way is to use a strap around the top of the thighs while in the traditional down dog position. The strap can be held by a partner or it can be secured to a heavy door knob.

For more information about down dog see Yoga Journal.

#9 of Asana Analysis Series