Yoga Therapy: Teaching Students with Ailments

In this article, renowned teacher and author Mark Stephens gives our readers insight into modern Yoga therapy’s roots and an overview of how Yoga teachers and therapists can work with students who have physical problems such as weak wrists, low back pain, neck pain, hamstring tears, and other issues. His book Yoga Therapy: Foundations, Methods, and Practices for Common Ailments is already a classic in the field.

“There are very few human beings who receive the truth, complete and staggering, by instant illumination. Most of them acquire it fragment by fragment, on a small scale, by successive developments, cellularly, like a laborious mosaic.”    —ANAIS NIN

Healing what ails us, whether physical injury or existential angst, is a leitmotif of Yoga dating to ancient times. Today, Yoga therapy is emerging from the shadows of intensely vigorous, workout-oriented Yoga, reaffirming the healthy transformative potential of Yoga. This growing trend might be associated with “leading edge baby boomers,” many of whom caught the largely countercultural 60s Yoga wave, but now at an average of 70 years-old are a bit more frail. There’s also growing awareness that Yoga can help with everything from alcoholism and PTSD to sprained knees.

Curiously, Yoga Chikitsa — Sanskrit for Yoga therapy — is the term coined by Tirumalai Krishnamacharya to describe the beginning level (“primary series”) of Ashtanga Vinyasa that he designed in the mid-1920s, blending several Hatha Yoga asanas with Danish gymnastics and British military calisthenics and teaching this method to Brahmin boys in the Maharaj of Mysore’s palace gymnasium. While the Ashtanga Vinyasa practice might be therapeutic for a very small population of healthy, athletic students for whom its vigorous, acrobatic and contortionist forms are safe and accessible, if one is young (with bones and ligaments still developing, old (with less resilient joints and brittle bones), or simply interested in Yoga sequences and postures that are informed by basic functional anatomy and kinesiology rather than the apparently random assortment of postures in the set sequences prescribed in Ashtanga, they might well follow another path suggested by Krishnamacharya.

Krishnamacharya wisely taught a very different Yoga chikitsa method to his son, T.K.V. Desikachar, who started practicing Yoga in his mid-twenties after years of stressful university studies in mechanical engineering. Desikachar more fully developed Yoga chikitsa as an individualized therapeutic system, ViniYoga, integrating asana, pranayama, meditation and Ayurvedic techniques in offering unique healing treatments. The contemporary Yoga therapy movement, including the International Association of Yoga Therapists (IAYT), is rooted in this tradition while bringing Ayurveda, evidence-based scientific medical insights, and other healing modalities into the inspirationally, intuitively, and experientially received wisdom of Yoga chikitsa.

Today’s Yoga teachers and Yoga therapists are similarly wise in advising students and clients to consider such an approach in sharing Yoga in general, and most definitely in sharing it with those with injuries and other challenging conditions.

Healing with Yoga

When practiced sensibly — in tune with one’s senses and with a commitment to ahimsa (non-hurting), aparigraha (non-grasping), svadyaya (self-study), abhyasa (perseverance) and vairagya (non-attachment) — Yoga can be a deeply healing and awakening practice. In teaching Yoga as a therapeutic healing practice, we adapt asanas, pranayama, and meditation practices to support wellbeing and wholeness in unique individuals, whether students in classes or one’s private clients, addressing health problems in a far more specific way than in general Yoga classes.

While many Yoga teachers are physiotherapists, psychotherapists, respiratory therapists and other licensed health professionals, most of us are not. Still, we can offer efficacious and holistic approaches to help students heal what ails them.

To do this well, it is important for us develop the knowledge and skills with which to guide students with appropriate adaptations. It is equally important for students to explore embodying this knowledge with an intuitive sense of efficacy in self-healing. We should also be informed by the best possible understanding of the students’ objective conditions and how different Yoga practices might affect them. This invites us into the deepest wells of learning and experience, exploring the tools of Yoga and other practices that help students heal, feel better, and live the best possible lives.

In doing so, we ideally tap into the rapidly expanding universe of knowledge shared in workshops, books and articles, a rich source of research-based insight into specific adaptive Yoga techniques for helping to heal. A lay understanding of human functional anatomy, kinesiology, physiology and psychology along with subtle anatomy goes far in helping us grasp and apply these insights.

Yet we need more than knowledge. The heart of the Yoga teacher-student or therapist-client relationship rests in the heart itself, in the compassionate, caring, and considerate qualities of interaction that most encourage students to feel safe and open to exploring and transforming more deeply inside.

Cultivating Healing Resonance

Human beings possess innate powers of self-curing and self-healing. Even when our self-curing powers fail, our self-healing powers can make our lives better. When our self-healing powers are strong, they support our self-curing powers, and with them the power of curative treatments. While there are many areas of illness and injury for which Yoga offers curative treatment, the primary therapeutic benefits of Yoga are in cultivating a sense of overall wellbeing and healing resonance. This therapeutic potential of Yoga is rooted in one’s personal Yoga practice – including the Yoga teacher’s own personal practice – and in the relationship between the Yoga teacher and his or her students. Working within the integrity of this relationship, we can better engage our students and elicit their needs and intentions in curing or healing what ails them.

In teaching Yoga either one-to-one or in a group class setting, we come into pedagogical (and hopefully inspirational) relationships with students. Our varied instructional methods, personal styles of interacting with students, and qualities of energetic presence profoundly shape the nature of these relationships. Some Yoga teachers teach Yoga with a directive method that assumes the student must learn it all from the teacher, giving specific instructions that the student is expected to follow. Other teachers share their knowledge and insight with students while encouraging them to explore in ways that fully empower them to learn from the experience and to adapt the practices in ways that makes sense to them.

In helping students heal, we ideally teach with empathy, kindness and compassion, creating a sense of healing energy– affirmative feelings and associations that foster trust and openness – that is an essential element in healing. Yoga chikitsa is ultimately a form of self-healing that involves clarity about one’s conditions, including conditions of emotional attachment and insecurity that can interfere in developing and maintaining a healthy relationship with one’s students and clients. This highlights the importance of maintaining one’s own personal Yoga practice, particularly those practices that instill emotional stability and mental clarity as awakening somatic beings.

Heart-Centered Communication

All of this is predicated upon skillful, informed, heart-centered communication with our students. The more skillfully we engage with our students, better understand their needs and conditions, and more naturally establish trusting rapport with them, the better we facilitate their self-empowerment in making the best choices they can in healing. This starts with mindful listening. Rather than listening only to words, in mindful listening we strive to hear the complete message, which might be conveyed by body language more than by words. Rather than passively receiving the words or other messages of a student, we more actively engage by being responsive. This can be as simple as saying “yes” in affirmative response to a student’s statements, posing questions that convey empathy and elicit greater responses, and paraphrasing back to the student his or her words to confirm that we are hearing their intended message. Rather than arguing when in disagreement with what a student says, we find positive ways to affirm his or her immediate sense of things and confirm our understanding and appreciation of what they are saying, yet also gently and clearly offer our view, inviting our students to consider a different perspective.

Bringing these qualities together, we can better assess our students’ conditions and respond to them in informed and compassionate ways. Ideally, we have learned at least basic tools of postural assessment in Yoga teacher training, enabling us to apply knowledge of functional anatomy to strategies for healing musculoskeletal ailments. Understanding how various asana, pranayama and meditation practices affect emotional states helps us in working with students experiencing anxiety and/or depression. Without crossing the line into professional medical scopes of practice, we can apply these insights to unique students who are experiencing specific ailments.

Here we look at four musculo-skeletal injuries commonly found in (sometimes incurred in) Yoga classes. With any injury, it is wise to seek professional attention and care. Remember that we are Yoga teachers, not medical professionals. In all that follows, do not do any postures or movements that cause or exacerbate pain. Any of the conditions discussed here could involve a far more serious underlying condition. Consult a medical professional for guidance. With each example, there are a wide array of additional beneficial adapted asanas as well and pranayama and visualization practices one can do that are beyond the scope of this brief article. [For more in-depth information, consult Stephen’s  book: Yoga Therapy: Foundations, Methods, and Practices for Common Ailments]

Tender Wrists

Arm balances, Surya Namaskaras (Sun Salutations), and various dynamic movements such as jumping forward from Adho Mukha Svanasana (Downward Facing Dog Pose) place tremendous pressure on the wrists while this delicate joint is in extension or hyperextension. This often leads to one of the most common Repetitive Stress Injuries (RSIs) in Yoga. Yet the only counterpose typically offered – where the wrist joint is in flexion or otherwise nurtured – is Padahastasana (Foot Hand Pose, in which the hands are placed under the feet in a standing forward bend). It is rarely held for more than a few breaths, might not be accessible to some students, and does nothing to strengthen muscles that support the joint.

Protecting and healing the wrists:

• If already tender, do not do arm balances, step (rather than jump) in transitions, and gently self-massage the joint throughout the day.
• After stepping, jumping or otherwise coming to the front of the mat from Adho Mukha Svanasana, standing asanas, or arm balances, always place the backs of the hands on the floor, including in all Sun Salutations.
• Stretch and strengthen the wrists with a variety of gentle exercises: slow-motion self-resisted flexion/extension, adduction/adduction, and circumduction through comfortably full range of motion (ROM); alternately fully spread the fingers and make tight fists; shake the hands and wrists; and explore other basic wrists therapy techniques before, during, and after practice.

Low Back Pain

Generalized low back pain is the most common musculoskeletal complaint across humanity. Poor spinal posture (starting in the feet, legs and pelvis, specifically deviation from pelvis neutrality) and intevertebral disk degeneration (a natural part of aging that is exacerbated by poor posture) are the primary causes. Postural deviations cause and reinforce related muscular balances (tightness and weakness) and dysfunction (underuse, overuse, and misuse), particularly in the iliopsoas, quadratus lumborum (QL), hamstrings, multifidus, rectus abdominus and transverse abdominus. These factors and conditions worsen in ill-formed, attainment-oriented, fast-paced, and unbalanced asana practices, often leading to injuries, some involving forceful teacher adjustments, especially in seated forward bends such as Paschimottanasana (Western Stretch Pose).

Protecting and Healing the Low Back:

• If already tender, do not do seated or standing forward bends in which the low back flexes), and only very gently explore mild back bends and twists while keeping the lumbar spinal segment close to its neutral (natural) form.
• Stretch and strengthen the iliopsoas. Stretch it in Anjaneyasana (Low Lunge Pose)
• With hyperlordosis and for general low back health, do slow, gentle, repetitive transitions in and out of Salabhasana A (Locust Pose A) to strengthen the multifidi, QLs, rector spinae and hamstring muscles. (It is extremely unfortunate and perplexing that in Ashtanga Vinyasa this asana and other beneficial low back asanas are not allowed until the Second [Intermediate] Series, while the Primary Series has several complex asanas and transitions that are highly correlated with low back injuries.)
• Also for hyperlordosis, strengthen the rectus abdominus with slow, gentle posterior pelvic tilts while in Viparita Karani (Active Reversal Pose, also called Legs up the Wall Pose); and the transverse abdominus with gentle lifting in Tolasana (Scales Pose) without rounding the lumbar spine. Stretch the QLs with Balasana (Child’s Pose) and gentle twisting in Bharadvajrasana A (Simple Noose Pose) and Ardha Matsyendrasana (Half Lord of the Fishes Pose).
• With a flat back (loss of the normal lordotic curvature of the lumbar spine), strengthen the iliopsoas with a highly modified Navasana (keep the knees bent and clasp the hands behind them to add support) and very slow movement in all hip flexion movements; strengthen the QLs with Salabhasana A movements as described above; and stretch the rectus abdominus with gentle Setu Bandha Sarvanghasana (Bridge Pose).
• When doing forward bends, always initiate and maximize the movement with forward rotation of the pelvis, not rounding the lumbar spine.

Hamstring Origin Tears

This is the most common musculo-tendonous injury in Yoga, which we typically experience as a slight pinching sensation near the sitting bones (ischial tuberosities), where the hamstrings originate. Although usually a mild tear, when continued misuse it can become more acute and chronic if not fully healed. A significant causal factor is that in Yoga asana practices we do a lot to stretch these muscles and very little to strengthen them. There are three other prime factors: 1) the ego in pushing too hard and far (often the teacher’s ego in pushing on a student); 2) pulling the gluteal flesh away from the sitting bones in seated forward folds (which concentrates the stretch at the vulnerable tendon attachment); and 3) moving too quickly when folding forward from standing (which can cause a neuromuscular reaction called “stretch reflex,” in which the muscles stops stretching despite one’s effort to do just that).

Protecting and Healing the Hamstrings:

• Allow acute tears to heal before stretching in ways that bring any pressure into the tendonous attachment.
• Do not rely on bending the knees to reduce pressure on the tendon. The bi-articular hamstrings cross the knee and hip joints; flexing the knee increases hip flexion (and thereby tension on the hamstring origin, unless lying supine or standing with thigh fixed).
• Very gently work and stretch the hamstrings with dynamic, resisted hip and knee flexion and extension while lying supine and clasping the big toe or using a strap around the foot.
• Lying supine, place one foot on top of the other to create resistance while slowly and gently flexing the knee through its full range of motion.
• Slowly lift and lower in and out of Setu Bandha Sarvanghasana (Bridge Pose) to use the hamstrings in a way that presses the tendon into its boney attachment at the sitting bone.
• Slowly and gently move in and out of Salabhasana A (Locust Pose A), focusing awareness in sensitive hip extension.
• Move slowly in and out of Utkatasana (Chair or Fierce Pose).

Generalized Neck Pain

The cervical spine is often subjected to potentially injurious forces in many asanas. Some asanas carry inherent risk of serious cervical spine and nerve injury. The clearest example is Setu Bandhasana (Bound Bridge Pose), in which most of the body’s weight is forced into the mid-cervical spinal segment while the neck is hyperextended. Prescribed dristi (gazing point) is another prime suspect in neck injuries, with students instructed to look at a specific point that in some asanas requires simultaneous rotation, lateral flexion, and hyperextension of the neck, often with the shoulders elevated and thus further compressing cervical disks and nerves. Other common causes of neck injuries in Yoga are cervical extension in backbends (which should always be done last in a backbend if at all); Setu Bandha Sarvanghasana (Supported Shoulder Stand) without elevation of the shoulders and elbows on a firm bolster; and Sirsasana (Headstand) for a many reason. (Although this writer continues to do these asanas injury-free after a quarter century, a common error among physically adept [or lucky] teachers is assuming our students have the same potential.)

Protecting and Healing the Neck:

• First and foremost, never do any asana in a way that creates sharp pain in the neck or forces cervical flexion or extension (such as interlacing the fingers under the chin and forcing the head back, as instructed in Bikram Yoga).
• If a student has a pre-existing neck injury, he or she should obtain professional medical guidance before attempting any asanas that place pressure in the neck.
• Remember that any action that strengthens part of the body will likely cause strain or other injury if done forcefully, repetitively without counterposes, or with a pre-existing precipitating condition.
• Asanas and movements in which neck muscles are used to support the weight of the head can be excellent for strengthening the erector capiti, levator scapulae, scalenes, sternocleidomastoids and other muscles that relate to the cervical spine.
• Always make cervical spine movements the last action in backbends and twists, and be even more sensitive in releasing the head forward in all cervical flexion positions.
• Do a variety of very gentle movements of the head (only very slight extension) with the arms positioned as for Garudasana (Eagle Pose).

The Healing Path of Yoga

Just like seers in the Vedic period, Arjuna in the Upanishadic days, and Patanjali in reflecting on the nature of the mind, human beings have experienced suffering and sought ways to make life better. Life in the modern world has the benefit of the greater insights developed across the span of human civilization, even as many of our contemporary ills arise from the pressures of modern life. Anxiety and depression, drug and other addictions, cancer and other ailments pervade our world. It is wonderful that we have Yoga!

Yoga is a potentially powerful antidote that also opens the portals of consciousness to greater wellbeing. To allow Yoga its greatest promises, remember that it is not how far you go, but how you go that most matters. And always breathe as though your life depends on it.

About the Author:

Mark Stephens’ fourth textbook for Yoga teachers is Yoga Therapy: Foundations, Methods, and Practices for Common Ailments. He lives in Santa Cruz, California and teaches globally. Learn more at markstephensyoga.com.