Friday, July 30, 2010

Asana Analysis: Headstand/Salamba Sirsasana

A headstand is something typically associated with gymnastics and youth. Children often do headstands in tumbling classes or on the playground. Why would any self-respecting adult want to stand on their head? Because when done properly, headstand proffers many benefits. Inversions increase venous return, improve blood flow and circulation of lymph. Inversions are thought to strengthen the immune system and to help balance the endocrine system. Headstand in particular can also increase shoulder strength, improve core stabilization and enhance concentration.

That said, headstand is not for everyone. It is an intermediate pose and is best learned under the guidance of a yoga teacher or therapist. Those with high blood pressure, eye conditions such as a detached retina, and those with neck pain or acute injuries should not attempt to do any version of headstand.

Muscles Strengthened: Deltoids, triceps, rotator cuff muscles, rhomboids, middle and lower trapezius, serratus anterior, pectoralis major and minor, abdominals, thoracic and lumbar extensors, gluteus maximus, quadriceps

Points of Body Awareness:
*Are you gripping your hands together? Clasp the hands gently in order to avoid unnecessary tension throughout the body.
*Is the top of your head resting lightly on the ground or do you feel a lot of weight and pressure on the skull or through the neck?
*Are the jaw and throat muscles relaxed?
*Do you feel your shoulder girdle engage to support most of your weight?
*Can you feel your navel or bladder drawing in toward the center of the body?
*Do you feel yourself lengthening from the core, up through the legs?
*Can you breath deeply and steadily?

To Modify: Practice the upper body mechanics of the pose and build up strength and endurance of the shoulders without worrying about balance by keeping the legs on the seat of a chair. Watch a demonstration of this technique.

To Challenge: Come in and out of the pose with total control, first by lifting and lowering both legs with the knees bent. As you get stronger, lift and lower both legs together with the knees strait. You can also change the position of the legs while in headstand. Try splits, straddles or butterfly variations, always maintaining stability through the shoulders and spine.

PT Notes: A full headstand requires a high degree of spinal stabilization and core strength. If the deep neck muscles are weak (longus colli or rectus capitus) or inhibited, the superficial muscles of the neck and jaw will likely be tense during headstand. Without adequate abdominal strength, the hips will remain slightly flexed. With this compensation, it is easier to balance because the posterior muscles of the trunk and hips do most of the work rather than the anterior muscles.

A 2006 study showed that modified headstand was effective in improving AROM and decreasing pain in patients with rotator cuff tears. I will write more about this study as a guest blogger for Mike Rheinold in an upcoming post.

See Yoga Journal for more detail.

Monday, July 26, 2010

The Living Spine by Ginger Garner MPT, ATC

I met Lisa last year when she attended a 2009 PYT training in San Francisco I gave on medical therapeutic yoga and the lumbopelvic spine. One of the topics I addressed was myofascial release and yoga, and Lisa recently asked me to elaborate on it.

The Mission
There is a high level of stress experienced by professionals who practice within the medical model today, and I believe it is associated with the skewed belief that we must or should “fix or cure” people. As a physical therapist who strives diligently to dive below the surface of a diagnosis in order to treat the whole person, I practice a different model. My day to day vision is to empower individuals, equip them with the tools they need for self-healing, and to be a facilitator rather than a clinical magician who “fixes or cures the patient.”

I believe our job as rehabilitation professionals is to provide a safety net and supportive environment for healing. Perhaps the most important value we can possess as a health care professional is to seek to play offense (prevent injuries and disease) rather than only being available (or able) to play defense (curing injuries and disease). This is the model I use when caring for someone whose is trying to prevent, or whose life is already impaired by, spinal dysfunction or disease.

The Living Fascia
The “Living Spine” refers to the role of fascia in spinal health. In my practice I apply the evidence base on fascia to yoga , which in 15 years of practice has evolved into a kind of hybrid medical therapeutic yoga that combines physical therapy and my other training in manual therapy, orthopaedics, Pilates, and women’s health.

I look at myofascial restriction often and early on in the evaluation process. In our hyper-stimulated, hyper-mobile society, I rarely focus on yoga as a way to mobilize clients. I mostly use yoga to stabilize them – physically, psycho-emotionally, energetically, socially, and spiritually. “Yogic” myofascial release then, I use only after I have addressed the individual’s static and dynamic functional stability. Myofascial release works beautifully with yoga as they are both proven to lower sympathetic activity.5

Fascia is defined as “dense, irregular connective tissue sheets in the human body, such as apneuroses, joint capsules, or muscular envelopes like the endo-, peri-, and epimysium.”1

Thirty years of research supports that the lumbodorsal fascia is indeed alive and exhibits an active and contributory connective tissue role, secondary to intrusion of muscle fibers2. Smooth muscle cells have been found embedded within the collagen fibers of the fascia cruris in humans.3 This finding suggests fascia affects postural stability and can limit spinal mobility in the individual, especially since the tension transmission occurring between the epimysium contributes to generation of muscle force.3,4 The same authors suggest that local thickenings of fascia can exhibit force on tendons and ligaments as well.

Fascia and You
Pain from myofascial restriction is multi-faceted, and can be caused by surgical incisions, medical conditions or disease, accidents, injury, inactivity, neural tension, stress, or poor breathing habits. Since tone of the fascia can be influenced by the autonomic nervous system, Staubesand states “any work on the fascia then, is work on the autonomic nervous system (ANS).”

One way I facilitate self myofascial release is through identification and correction of poor breathing habits, which directly affects the ANS. Although I also practice passive myofascial release (MFR), or me treating the patient, I prefer to have the individual take a more active role. An active role allows the individual to cultivate confidence, awareness, and it puts them in charge of managing their own health. Schleip calls this approach that of a “humble midwife rather than a heroic technician,” and in my years of experience I have found it also greatly reduces stress and risk of clinician burnout.

One of the precepts of the Professional Yoga Therapy method is that the breath receives priority. I always begin and end with the breath; and, I revisit it as often as needed during a session to help a person soothe the nervous system and down-train their actions/reactions to movement and life.

The abdominal breath is the long accepted gold standard for relaxed, diaphragmatic breathing. However, I only use this breath during passive, restorative type yoga postures and not for active yoga or ADL completion. The abdominal breath is absolutely the first step toward myofascial freedom (and freedom from pain!) in the individual. This breath type can be progressed later into the three or four part breath (dirga pranayama). Both breath types focus on alveolar ventilation, elongation of the breath, decreasing sympathetic activity, and equalization of the inhalation/exhalation. They also encourage metering of the breath – or conscious control.

You can download a free copy of the abdominal breath practice here. (also included is an excerpt of research on how abdominal breathing impacts postpartum health)

Comfort Measures
When starting a yogic breath practice it is important to create a comfort zone for the individual. Seated meditation poses may not, and often do not, typically work for the average American without much experience in yoga. I typically begin with supported corpse using blankets and bolsters. For their home practice I educate them on a comfortably reclined posture in bed. I use a blanket fold I call the “three tier approach,” which a person can adapt to hundreds of postures. (the three tier approach is shown in the abdominal breath download)

In addition, it’s important to use appropriate (non-fluorescent) lighting and create a peaceful d├ęcor and atmosphere in your practice. Lastly, use of imagery, mottos (mantras) or inspirational quote, or guided meditation further helps relax a person into their breath and their center of being.

For more information: Other methods that can be used are taught in the 2 day Spine course, and include “pre-asana,” yoga posture application, a model for evaluation of the client, as well as a study of pelvic floor interaction and relationship (“bandha” or lock work) with the lumbopelvic spine.

Ginger Garner MPT, ATC, ERYT is a licensed physical therapist, athletic trainer, and professional yoga therapist specializing in women’s health. She is a longtime advocate for mothers and women, and is the author of Breathing In This Life at and a forthcoming book on prenatal and postpartum fitness. Ginger is founder of Professional Yoga Therapy, an integrative rehabilitation and medical yoga continuing education program for licensed health care professionals. Ginger can be reached at Ginger lives on Emerald Isle, off the coast of North Carolina, with her husband, two young sons, and her 15 year young Labrador retriever, Owen.

*Photo is of the author in her late third trimester during her second pregnancy, practicing a breathing practice she designed for labor and delivery during ball assisted squat/backbends. It is a functional example of the way the author employs self-myofascial release using breath and posture for the prenatal season of women’s health.

1. Schleip et al 2005
2. Schleip 2003, Schleip 2005, van den Berg and Cabri 1999, Manuel et al 2008, Kruger 1997, Rolf 1977, Yahia et al 1993
3. Staubesand and Li 1996, Schleip et al 2005, Garfin et al 1981, Huiking, 1997
4. Schleip et al 2005, Barker et al 2004
5. Schleip 2003, Van den Berg and Cabri 1999
6. Garner 2005-10 Medical Therapeutic Yoga for Evaluation and Management of the Lumbopelvic Spine.

Wednesday, July 21, 2010

Asana Analysis: Mini-Cobra

This is a modification of Bhujangasana that is extremely useful for for anyone who practices yoga. It helps to increase the mobility and awareness of our mid-back (thoracic spine) and shoulder blades (scapulae). Consider using mini-cobra instead of up-dog during sun salutations for the first few rounds until the body is warmed up.

Even in the absence of injury, this is a good posture to practice before doing more vigorous backbends. We are all more stiff in our thoracic spines given our postural habits, activities of daily living as well as the inherent anatomy of the thoracic spine. By learning to work with scapulo-thoracic region, we can avoid overcompensations in the lower back and neck during postures such as cobra, up-dog and upward facing wheel.

Muscles Strengthened: Middle and lower trapezius, rhomboids, cervical and thoracic extensors

Muscles Stretched: Pectoralis minor, rectus abdominus, upper intercostals

Points of Body Awareness:
*Begin with the forehead resting on the ground, the fingertips are under the shoulders and elbows point up toward the ceiling.
*Before lifting the head and chest, draw the navel toward the spine (engaging transverse abdominus) and lift the shoulder blades towards the ceiling, squeezing them together.
*Lift the the head and chest away from the ground without pushing with the arms.
*Can you lift the hands one inch off the ground? If you are using your spinal muscles to keep the head and chest lifted then it should be easy to lift the hands.
*With the hands back on the ground, can you imagine dragging yourself forward on your belly? This should be an isometric action, meaning there is no visible movement that occurs but you should feel more muscular action around your shoulder blades and you might feel the chest spreading and opening a bit more.
*Keep the gaze on the ground about three feet in front of you. This will help to prevent hyperextension of the neck.
*Hold for at least 6 breath cycles. Be aware of the shoulder girdle and notice if the shoulders creep forward.

To Modify: If there is any pain in the neck or back try keeping the forehead down and just work on drawing the shoulders back.

PT Notes: This is a great posture for working on postural awareness, level 1 scapular stabilization and spinal extension ROM. It’s great for patients with osteoporosis, rotator cuff injuries, neck injuries, postural syndromes, etc.

Monday, July 19, 2010

More Robots in Rehab

I saw this link about Rex the Exoskeleton yesterday and I just had to share it. This is great! Granted, it doesn’t allow ‘normal’ walking and can’t replace the speed and efficiency of a wheelchair but the physical and social benefits must be terrific. Standing has long been an important aspect of rehab for those with paralysis of the legs but it is typically done in a standing frame in which you are immobile. I’m sure that it would be quite tedious to stand locked in place for hours a day. This new device is great because it provides all the physiologic benefits of standing but allows the user to move and to be much more independent.

The $150,000 price tag does seem exorbitant and hopefully that price will come down as the technology improves and production ramps up. But when you consider the benefits, the price seems to be more reasonable. Standing improves circulation and increases bone density. It decreases the incidence of joint contractures, pressure sores, bladder and bowel problems. It lessens the chance of developing lung problems or blood clots. If this device can keep users out of the hospital and away from extra medications, it may actually save money in the long run. What are the chances that insurance companies will help pay for this kind of technology? I hope they will.

This video describes one guy’s experience with the robot and how it has helped him:

Thursday, July 15, 2010

The Value of Discomfort

I recently spent a weekend in Phoenix where it was 112 degrees. It was physically quite uncomfortable but I did end up relaxed and recharged so it got me thinking, what does it really mean to be ‘out of your comfort zone?’ Comfort is something we crave when we are tired, weary, sick, exhausted, frightened. Think: favorite pajamas, a perfectly worn-out, handcrafted quilt, luxurious pillows, mac and cheese, fresh-baked chocolate chip cookies, a cool cloth on a hot forehead. But surely constant comfort would mean lack of growth. I don’t have to tell you where we’d all be if we laid in a comfortable bed, eating chocolate chip cookies all day. Comfort needs to be balanced, but by what exactly? Discomfort? Effort? Change?

Discomfort can be physical. It can be mental, emotional or it can be spiritual. Can leaving our comfort zones be beneficial in all these ares? Yes. Physical discomfort is a part of getting in shape. When our muscles burn, we get stronger. Mental discomfort is necessary to help us learn. Learning a new language or working out a complicated math problem isn’t comfortable, it’s hard work. We might even get a headache from all that fierce concentration. But it creates new connections among our neurons. It improves the physical health of our brains. Emotionally, we are usually better off when we get out of our comfort zones, when we do the thing that we fear most. This might be forming new relationships or confronting a problem in an existing relationship. Recognizing our own emotional problems such as addictions or depression and asking for help can be extremely uncomfortable but it’s always the first step in solving those problems. Spiritual discomfort can be evidence of an empty heart or a questioning mind. It can help us to seek answers and strengthen our spiritual confidence. Some of the greatest spiritual leaders were not blissfully comfortable in their faiths. St. Teresa and Mother Teresa are two examples that come to mind, of women who experienced doubt and grief about their faith yet were able convey the love and glory of God.

I think it is useful to look at our lives and assess where we abide within the comfort spectrum. Look at each of these areas; physical, mental, emotional and spiritual and ask yourself whether you ever leave your comfort zone. Is there room for growth? There also may be areas where you don’t allow yourself enough comfort. You may push yourself physically or mentally so you don’t have to think about yourself emotionally. Or you may be emotionally unstable as a way to remain spiritually unruffled. (I’m thinking of zealots, terrorists and those willing to inflict harm on others who don’t comply to their own religious beliefs) Finding a balance of comfort and discomfort in all of these four areas will surely benefit our own health and will likely create harmony with those whom we interact with.

Yoga teacher, Judith Hanson Lasater once said that there is a difference between comfort and contentment. This struck me as an incredibly important distinction. Is it possible to be content with your discomfort? This was said in reference to the physical experience of a yoga posture but I think it applies in our mental, emotional and spiritual lives as well. If you are experiencing pain, can you find contentment? If not, then the pain is likely to be overwhelming and harmful. Try to get away from the source of pain and if that is not possible, then ask for help. That help might come in the form of medicine or therapy or counseling. But if you can find contentment in the discomfort then you can be assured that you are changing for the better, evolving and growing stronger.

Like chilling out on a scorching hot day.

Tuesday, July 13, 2010

Asana Analysis: Cobra/Bhujangasana

This seemingly simple posture is actually much more difficult than it appears. It requires simultaneous ‘opening’ of the hips, shoulders and torso. The vast majority of people are tight in at least one of these areas if not all three. And for people who are flexible, this posture is one that is easy to cheat on by holding the posture in a passive manner without any internal support or stabilization.

Muscles Strengthened: Middle and lower trapezius, rhomboids, triceps, transverse abdominus, multifidus, thoraco-lumbar extensors

Muscles Stretched: Pectoralis minor, rectus abdominus, intercostals, iliacus, psoas

Points of Body Awareness:
*The feet and legs should press firmly into the ground. Traditionally the legs are together however hip-distance is fine as long as the legs are in a neutral position and not splayed outward.
*Can you rise up from the ground like a cobra? Rather than peeling up from the floor, try rising up first from the lower back by using your abdominals. Then continue to come away from the floor segmentally, from the lower spine. The head is the last thing to come up. This is especially important for those who are flexible and need to incorporate more stability into their poses.
*Is there any compression or pinching in the low back? If so, come back down and try again or try a modification.
*Notice the alignment of your shoulders. Are they hunched up toward the ears? Are they rounded forward? Try to draw the shoulders down and back to lengthen the collar bones and open the heart.
*Lengthen down through the arms but make sure that your elbows are not hyperextending.
*Keep the gaze strait ahead. Lengthen through the crown of the head.
*This can be an excellent posture for facilitating deep breathing. Try to draw the inhalations to the bottom of your lungs. Exhale slowly through the nose.

To Modify: A folded blanket or block can be used under the pelvis to decrease the stretch on the hip flexors. Make sure that the pubic bone is fully supported by the prop. For less spinal extension ROM try sphinx posture, propped up on the elbows or mini-cobra which I will describe in detail next week.

PT Notes: Most PTs are very familiar with ‘prone props’ and the benefits and precautions of spinal extension exercises. What differentiates cobra from ‘prone props’ is the incorporation of total body awareness. Sure, the lumbar extension may help to centralize a herniated disc but we can use cobra to assess and/or treat tightness in the anterior body, train scapular awareness and to improve respiration.

See Mike Reinhold’s recent musings on why cobra might be an exercise that is undervalued and underused by PTs.

See Yoga Journal for more details.

Wednesday, July 7, 2010

Asana Analysis: Reclined Hero/Supta Virasana

Reclined Hero/Supta Virasana:
This is a variation of last week’s pose, Virasana, but I felt that it deserves a post of it’s own because it has it’s own benefits and challenges. In addition to stretching the legs and feet, it also opens up the front of the entire torso, reversing the forward hunching posture we all succumb to throughout the day. This opened-up posture is good for digestion and for the lungs. The challenges of Supta Virasana are the same as for Virasana but in addition, the back can be stressed and the knees can be even further stressed due to lengthening of the the thigh muscles that cross both the hip and knee.

Muscles Stretched: Quads (including rectus femoris), tensor facia lata/iliotibial band, iliacus, psoas, abdominals anterior tibialis, flexor digitorum longus, flexor hallicus longus

Points of Body Awareness:
*First settle into seated hero pose. Be sure that you are pain-free and grounded before moving on.
*Lean back, slowly walking the hands behind you. Progressively come down to the elbows, then all the way down so the back is on the ground (or a bolster).
*Have the knees popped up away from the ground? Have the knees flared out so that they are now wider than hip distance? If so, come back up and use a bolster or add more height to the bolster.
*Is the back arched up? Are the lower ribs thrusting upward toward the ceiling? Are the bony points on the front of the pelvis (ASIS) tilting down toward the thighs? If any of these are the case, then use a bolster.
*Once you are properly grounded, with the knees in alignment and the back supported, see if you can ‘lengthen’ the thigh bones while at the same time ‘grounding’ the lower back and pelvis.
*The last step is to reach the arms overhead. Notice if this changes the shape of the lower back or the alignment of the ribcage.
*Do at least 10 slow, diaphragmatic breaths here.

To Modify: Props, props, props! Most beginners will require a bolster in order to do this pose properly. Even if you are able to lie all the way down, try a restorative version of Supta Virasana. Build an incline by placing a bolster on top of a couple of blocks. The head will be higher than the navel. Use a rolled up blanket or towel under the neck. You can also use folded blankets or pillows under the arms. Use a folded blanket under the feet and knees to pad the bony prominences. This restorative version will allow you to stay in the posture for several minutes and to really receive the full benefits of the posture.

PT Notes:
This is another pose that I have not used with patients but enjoy doing myself. Obviously this posture requires much precaution for any patient with problems of the knees or lumbar spine. The restorative version of this pose can provide great benefits with much less stress on the joints. Restorative postures are known to induce the relaxation response which decreases heart rate and blood pressure, reduces muscular tension, and reduces activity of the autonomic nervous system.

Backbending postures such as Reclined Hero are normally invigorating and some say, stimulating to the kidneys and adrenal glands. But supported, restorative backbends create a deeply relaxing and meditative state of mind, much different from the excitement and ‘high’ of unsupported backbends. Supported forward bending postures are deeply relaxing as well however they can also feel as if you are disconnecting from the world and from the body. With supported backbends it feels as if there is more awareness of the body but in a very calm state. Restorative Reclined Hero is a great option for working on breath awareness and relaxation training.

For more details see

Image from