Friday Practical Pointers Who Should Avoid Certain Shoulder Movements

by Baxter

Judith Valerie, Age 63

Today let’s look at who should avoid certain movements at the shoulder, specifically the movement of the upper arm bone at the shoulder joint (the glenohumeral joint). This is where the upper arm bone meets the shoulder blade (the scapula). 

The movement of your shoulder is actually quite complex; it's not just those two bones moving relative to one another. Instead, when your arm bone moves in different directions, the shoulder blade slides and glides around on your back and side rib cage, too. Although this makes the shoulder joint’s movements more complex than the hip joint, the shoulder has the same six basic movements, which can be combined in various ways as you do yoga poses, sports, or movement arts, or simply move about the world:

1. Flexion: Reaching your arm forward of your body, whether parallel to the ground or up overhead as far as it can go, for example, bringing the arms forward and up in Tree pose (Vrksasana). As the upper arm bone moves in flexion, the shoulder blade slides around and up the side of the rib cage. You also move in flexion when you release from extension, for example, releasing arms from Locust pose (Salabasana). 

2. Extension: Reaching your arm back behind your body, for example, in Locust pose (Salabasana). As you make this movement, your shoulder blade slides down and back towards the spine on the back of the rib cage. You also move in extension when you release from flexion, for example, releasing arms from Tree pose (Vrksasana). 

3. Abduction: Taking your arm from alongside your body either out to your side, for example, for Warrior 2 pose (Virabradrasana 1), or continuing through an out-to-the side position all the way up to alongside your head, for example, in Arms Overhead pose (Urdva Hastasana). Interestingly, the shoulder blade action is the same as in flexion. 

4. Adduction: Returning your arm back alongside your body, either from an out-to-the side position, for example, from Warrior 2 pose (Virabradrasana 2) or from an arms overhead position, for example, from Arms Overhead pose (Urdva Hastasana). If you add in a little flexion, you can continue the adduction across the front of the body, for example, in Eagle pose arms (Garudasana. If you add in a little extension, you can continue adduction across the back of your body, for example, in Reverse Prayer pose (Paschima Namaskarana). The shoulder blade action is the same as with extension.

5. External Rotation: Rolling the upper arm bone out away from the midline of your body (the lower arm bones follow). For example, you use this action in Savasana when you turn your elbow creases and palms towards the ceiling.

6. Internal Rotation: Rolling the upper arm bone in towards the midline of your body (the lower arm bones follow). For example, you use this action when bringing the bottom arm of Cow Face pose (Gomukasana) into position. 

Cautions

Now let’s look at who should avoid or minimize certain shoulder movements. Keep in mind, however, that we want to maintain as much of our full range of movement of the shoulder joint as possible. So, in many instances, my caution will not mean “don’t” or “never,” but rather approach cautiously and stop if the movement worsens pain. In general, you should avoid or minimize any shoulder movement if you have: 

1. Acute painful injury to the shoulder area that gets worse with that movement. 
2. Chronic issues that flare with that movement, such as those with shoulder joint arthritis, rotator cuff injuries that have not been repaired, painful bone spurs, chronic bursitis, and those at risk of dislocation of the shoulder joint (much more common that in the hip, for instance). 

Note: Those with a diagnosis of frozen shoulder will actually have to move into the range of motion that starts to be painful, and gradually increase the range of motion over time, even if it hurts. In contrast, this would not be the case, for those with a rotator cuff tear that has not been fixed. This means you really need to get your shoulder issues fully checked out by a good orthopedic doctor before you can know what to avoid!

Now for the specific movements. Who should avoid or minimize the following movements?

Flexion

1. Those with shoulder impingement issues, such as rotator cuff tears or bursitis, that your doctor says warrants avoiding this movement. 
2. Those prone to shoulder dislocation (check with your doctor) when this action occurs in weight-bearing poses, such as moving into Downward-Facing Dog pose (Adho Mukha Svanasana) from an all-fours position or kicking up into Handstand, where the stress on the joint increases. 
3. Those with thoracic outlet syndrome may only be able to take their arms briefly into full flexion, and should lower them down if symptoms arise. 

Extension

1. Those with shoulder impingement issues, such as rotator cuff tears or bursitis, that your doctor says warrants avoiding this movement. 
2. Those prone to shoulder dislocation (check with your doctor) when extension occurs in a weight-bearing pose, for example, coming into Upward Plank pose (Purvottanasana) from Staff pose (Dandasana), or when it occurs in non-weight bearing poses, for example, when you clasp your hands behind your back in Standing Forward Bend (Uttanasana) and lift your hands away from your lower back. 

Abduction

1. Those with acute strain of the muscles that get stretched via abduction, such as the latissimus dorsi and certain parts of the trapezius and pectoralis muscles. 
2. Those with certain types of shoulder impingement issues, such as rotator cuff and bursitis. 
3. Those with risk of certain types of shoulder dislocation (check with you doctor) when the arm is taking to the extreme of abduction overhead, such as the top arm in Revolved Janu Sirsana when clasping the big toe of the straight leg. 
4. Those with thoracic outlet syndrome may only be able to take their arms briefly into full abduction, and should lower them down if symptoms arise. 

Adduction

1. Those with acute strain of the muscles that get stretched with adduction, such as the deltoids, and certain parts of the trapezius and pectoralis muscles. 
2. Those with certain types of shoulder impingement issues, such as rotator cuff and bursitis. 
3. Those with risk of certain types of shoulder dislocation (check with your doctor) when the arm is taking to the extreme of adduction behind the back, such as the bottom arm in Cow Face pose or in Reverse Prayer position and in many binding poses when the arm comes behind the back. 

External Rotation

1. Those for whom the movement creates a pinching or painful sensation at the shoulder joint area. 

Internal Rotation

1. Those for whom the movement creates a pinching or painful sensation at the shoulder joint area. This can often be the case with issues of the subscapularis muscle, one of the four rotator cuff muscles. 

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Friday Q A When to Eat

The Bowl of Milk by Berthe Morisot

Q: One thing that often has prevented me from having another 1/2 hr. session (at home) in the afternoon is the problem of eating. I seem to remember learning I need to wait at least 1 1/2 or 2 hrs. after I eat before doing my next asanas. Is this true? What is the shortest time one needs to wait before doing a workout - or a session (I hate calling it a workout, but hopefully you get it). I do my a.m. yoga before breakfast - but each day is different time wise & eating with a wait period before yoga becomes a real challenge. Could you give me some suggestions?

A: I tell folks that it depends on their digestion patterns. So I will often have a light meal an hour before practice without any ill effects. Others may find it prudent to wait a little longer, so as to avoid acid reflux or discomfort in forward bending or twisting from the stomach still being full. 

—Baxter

A: So many rules! It reminds me of the one they used to have when I was a kid about how you had to wait one full hour after eating before going back into the water. Have you ever tried practicing soon after eating a snack? How did it feel? If you felt uncomfortable (or worse), then it's probably not a good idea for you. But if you felt fine, I say go for it. Personally I do it all the time, with no ill effects. And I have heard that in India for people who can't practice on an empty stomach (some people, like me, get low blood sugar), they recommend yoghurt or milk before practice. (Confession: one time my friend and I ate hot fudge sundaes just before an advanced yoga class. Then, for the first time ever, the teacher started the class with Headstand. After class, we confessed to the teacher. He was very sympathetic! He said, "Oh, you should have told me. I would started the class with a different pose.") 

—Nina

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Friday Q A Ostepenia of the Spine and Headstand

Q: I am 63 years old and have osteopenia of the spine. What are your thoughts of headstand for those of us with osteopenia of the spine? I have taken yoga for several years. My teachers are wonderful and all are Iyengar certified as senior teachers. I have not yet shared with them my recent diagnosis. I appreciate your thoughts on this question.

A: As a general rule, I’d say don’t do it. As we have written about before, the spine is the number one sight for fractures secondary to osteoporosis and osteopenia means your spinal bones are already thinning. And although the thoracic spine is the most common area for wedge fractures to show up in OP, lumbar and cervical fractures happen, too. The human cervical spine—as you probably already realize—is not structured to bear weight on the head, no matter how much you might love Headstands and Shoulderstands (also not a good idea if you have osteopenia of the spine) or what your teachers might like to believe. The cervical region of the spine has the shortest vertebrae and the thinnest discs of anywhere in the spine, because it is evolved only to have to bear the weight of your head, not your body resting down on your head.

I also recommend sharing your diagnosis with your teacher. Now. If your teachers are not particularly concerned about the possible negative effects of Headstand on your spine, you might seek out a new teacher. This does not mean that you cannot do certain inverted postures. Legs Up the Wall is generally safe as an alternative, and if you can get up and down by pivoting mostly at the hip joints to use a “Headstander” (a special prop that allows a variation of Headstand where the head dangles toward the floor but does not rest on the floor) to go upside down, you could give that a try. But do remember that you need be careful about forward folding and it’s potential negative impact on the thoracic and lumbar spine with OP. 

As senior Iyengar teacher Ramadan Patel once said during a workshop on Shoulderstand when someone was bemoaning the fact they might not be able to do the pose again, “Nobody ever attained enlightenment doing Shoulderstand! It is not big deal. Let it go.” It was helpful to actually hear that back when I was able to do Shoulderstand and Headstand without a second thought. These days, I myself skip Headstand to keep my delicate cervical spine happier.

—Baxter

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Friday Q A Cervical Radiculopathy

Clear Upward Lengthening of Cervical Spine in Mountain Pose

Q: I'm a 68 year-old female and have recently been diagnosed with cervical radiculopathy. While my yoga instructor is usually very helpful neither she nor the physical therapist I saw can tell me what poses to avoid and which ones can be helpful. My MD is a yoga practitioner and recommends hot yoga. I don't feel that is an option for me. My Dr. is not helpful enough. Pretty much "don't do it if it hurts". So I now am pretty sure what I shouldn't do. It's the poses that are beneficial I need help with. Any suggestions? 

A: As I reviewed the questions we have received over the years, I found that neck pain is near the top of the list. I have written about neck pain several times in past, and in my post Friday Q&A: Safe Neck Movements, I cover quite a few causes and kinds of neck pain, and make some general recommendations about safe neck stretching and mobilizing movements. 

However, today’s reader has a slightly different situation going on from what I have previously addressed, as she mentions a diagnosis of cervical radiculopathy.  This condition occurs when one of the cervical nerves that extend from spinal cord in the neck becomes pinched and compressed, often by a bulging disc, resulting in damage to the nerve and unpleasant and painful symptoms. This condition is potentially more serious than some other causes of neck pain and stiffness, as the nerves being pressed on could eventually lead to more permanent nerve damage, resulting in weakness and loss of normal function, especially in one arm. So, if our reader has only seen her family MD about this, my first recommendation is for her to consider seeing a neurologic specialist and getting a second opinion on her condition and cautions for her yoga practice. 

And although I am always pleased to hear of doctors who are yogis and who consider recommending yoga to their patients as a part of a well rounded therapeutic program for treatment and healing, I personally would not recommend hot yoga in this case, especially for an older adult who might react negatively to the extreme heat of the practice room and because—from my personal experience—the typical hot yoga sequence would not be appropriate someone with our reader’s condition (again, just my opinion hot yoga lovers!) 

Our reader’s physical therapist and local yoga teacher may have been perfectly justified in being reluctant to offer advice on what to do and what to avoid, due to the greater chance of cervical radiculopathy being a more serious source of neck pain. That said, poses to avoid may be obvious. First of all, avoid any poses where you are bearing weight on your neck and head, including Headstand (Sirsasana), Shoulderstand (Sarvangasana), Plow pose (Halasana), Rabbit pose (Sasangasana), Fish pose (Matsayasana), and so on. 

Since forward bending of the neck, with or without some rotation, often aggravates or encourages ruptured discs to press on nerves, avoid those movements, too. Examples of forward bending the neck are the chin lock (Jalandara Bandha) and letting your head release to the floor in Downward-Facing Dog pose (Adho Mukha Svanasana). And if you are not certain if the pressure of some unusual pose is safe for your neck, such as the all fours twist with your head on the floor, which is sometimes called Thread the Needle pose (Parsva Balasana) and which Melina Meza calls Reaching Under the Bed pose, then just don’t do it! 

As for poses or movements that are safe, one generally safe pose to work on is Mountain pose (Tadasana) with a clear upward lengthening of your cervical spine, especially if you have Head Forward Syndrome or Text Neck (see Friday Q&A: Text Neck and Head Forward Syndrome). By actively working this way on a regular basis, you can encourage a healthy, more natural alignment of you cervical bones and discs, which could potentially take some pressure off the impinged nerves that are causing pain, numbness, and tingling that sometime accompany this condition. In other words, work on good posture as often as you can! Other standing poses, such as Arms Overhead pose (Urdva Hastasana), Powerful pose (Utkatasana), Warrior 1 and 2 (Virabradrasana 1 and 2), could also be potentially beneficial, as long as you monitor your symptoms as you work on neutral neck alignment, slight rotation (as in Warrior 2) and slight extension (as in Powerful pose and Warrior 1). Also, you could cautiously try poses that strengthen the back muscles of your neck and those that take your neck into extension or mild back bending shape, such as a low version of Cobra pose (Bujangasana) or Locust pose (Salabasana) practiced dynamically. 

In summary:

1. Get more information about your condition from an expert. 
2. Avoid obvious poses that aggravate of your symptoms. 
3. Mindfully try some of the poses where your neck is aligned more neutrally. 
4. Let your body’s response to the poses guide you to finding poses that support good posture and help you maintain some flexibility and strength in your neck, without creating pain. 

I hope you find this helpful!

—Baxter

DISCLAIMER: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities.

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Friday Q A Mortons Neuroma

Q: I have a question about flat feet and Morton's toe. I'm a 57 YO man who walks a lot and I have both. I always have difficulty balancing on one foot—tree, eagle pose, etc., and have recently had a bout with Plantar Fasciitis showing up in my left heel. No fun. I was at a yoga class yesterday and some poses felt good, others hurt. When I left the class, I literally limped home and iced it for 1/2 hr. then heat, then rest. I had acupuncture at Quan Yin this morning for it and bought new, sturdy shoes and heel pads. It feels a little better today. Can you suggest any asana or other treatment I can do at home that may help speed the healing process and prevent future trouble?

A: This question from last week was really a three-parter, and I covered flat feet with you all last week (see Friday Q&A: Flat Feet), so let’s turn to the second issue that came up for our student last week, Morton’s neuroma. It turns out this particular condition can cause pain in the ball of the foot, as we shall see below. 

According to the Mayo Clinic, “Morton's neuroma is a painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes. When it develops, it may feel as if you are standing on a pebble in your shoe or on a fold in your sock. Morton's neuroma involves a thickening of the tissue around one of the nerves leading to your toes. In some cases, Morton's neuroma causes a sharp, burning pain in the ball of your foot. Your toes also may sting, burn or feel numb. Morton's neuroma may occur in response to irritation, injury or pressure. Common treatments for Morton's neuroma include changing footwear or using arch supports. Sometimes corticosteroid injections or surgery may be necessary.”

Interestingly, there's no outward sign of this condition, such as a lump or swelling on top or bottom of the foot. Instead, any of the following symptoms could appear: a feeling as if you're standing on a pebble in your shoe, a burning pain in the ball of your foot that may radiate into your toes, or tingling or numbness in your toes. We don’t know what causes this problem to develop, but it is theorized that irritation, pressure or injury to one of the nerves that lead to your toes may be the culprit. High-heel shoes, high-impact sports or sports with tight fitting shoes (can you say sport rock climbing?) or the presence of other foot deformities are all considered risk factors for developing a Morton’s neuroma. I could hypothesize that our student’s flat feet may have put him at risk for developing one of these buggers, but I don’t know about other activities that he was doing when it showed up. Obviously, the first two risk factors are addressable with lifestyle changes and choices.  Not so much the foot deformities.

If you go in for evaluation for foot pain on the ball of your foot, your doc will likely press around on the foot, especially between the third and fourth toes, to see if you are tender there or have a fullness that is not visible from the exterior. In addition, X-rays may be ordered to rule out a fracture as a cause for your pain, or an ultrasound may be used to look for the swelling of the nerve indicative of a neuroma. Typical western medical treatment usually starts with the least expensive and simplest approach. This could include over the counter arch supports and pads to take pressure off the neuroma. Your doc might go so far as to recommend you get special customized arch supports made for your shoes. Another fairly common treatment involves injection a steroid medication into the swollen area, as it is a strong anti-inflammatory medication. There are three other more extreme surgical approaches that are invasive and beyond the scope of this blog post. My hope is that you would not have to go to that extreme.

The folks at the Mayo Clinic do have some other ideas that could help, which are pretty common sense, too, like taking anti-inflammatory medications like aspirin or ibuprofen, as they can help with pain and swelling. Or try an ice massage. Regular ice massage may help reduce pain. If you have not already changed your footwear, what are you waiting for? Get rid of those heels and make sure the box of your shoes is wide enough!  Finally, they suggest you give your foot a break. For a few weeks, reduce activities such as jogging, aerobic exercise or dancing that subject your feet to high impact.

How might yoga fit into this healing process? Well, I, and many of my students, have noted that regular asana practice leads to a slight widening of the feet. This may be because the practice is done with bare feet (no shoes!). Regardless, this additional space might translate into enough space between your metatarsals to relieve the pressure on the nerve and allow healing to take place. We also often encourage students to spread their toes wide, which could travel upstream a few inches and also provide some much-needed space in the front foot. Finally, a modified practice, done with the buttocks supported on a chair for standing pose variations, as an example, could keep much of your body active while allowing your feet to have less pressure on them. And, of course, a regular practice of inverted poses could relieve all of the blood pressure effects of normal upright walking and standing, giving your feet a real rest. I’d recommend Legs Up the Wall as a “must do” on a daily basis for healing and recovery.

Next time, we’ll look at heal spurs in the mix of the other things our student has going on.  Until then, tread lightly!

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Friday Q A When to Change Classes

Q: I have been in one yoga class for a long time. I am not finding myself having more difficulty with poses as the years go on, but I’ve started thinking about when that might happen. If at some point I can no longer do most of the poses in class, I would of course know it’s time to move to an easier class. Do you have other thoughts on when/why to change classes? I’m not talking about responding to a sudden change in physical status, such as having broken or strained something, but rather thinking about longer term changes that are likely (?) to come.

A: This is a very interesting question. In a sense, you are asking about how one prepares for the inevitable changes that accompany aging. Obviously, we all are aging every day, and at some point, more significant limitations in our physical abilities will arise. In some eastern traditions, as a way of confronting these changes, the student is taught to meditate on change, aging and even death. The fear that can accompany these things is considered an obstacle on the path of yoga, and if addressed and worked with and through, is considered progress towards yoga's goals.

And more specific to your inquiry, although you might choose to attend an "easier" class as time goes on when poses that were once easy become too much or just no longer appropriate for you, you may not need to change classes. As an example, I attend an advanced class once a week, and many of the seasoned practitioners in that class no longer do certain poses that come up in the course of class, but still find it valuable to be with the teacher and the community, simply substituting appropriate alternatives when needed. Since taking public class is so much more than simply the performance of difficult poses, and you may be getting a lot from being in the presence of a mature teacher and wonderful fellow students, don't be quick to jump ship, just because your vessel is getting a little older!

Finally, I believe somewhere in my past posts, I have spoken about the stages of life and the recommended adjustments in practice that Krishnamacharya and Desikachar recommend (see here), and in their estimation, there is a natural and expected shift away from so much asana as we age, and doing more meditation and pranayama as we get older and are, in many ways, more prepared and ready for these more subtle practices. That may be something to start working towards now, while you are fit and able.

—Baxter

A: In my opinion if you’re exhausted after your class then it is time to reevaluate your goals in going to yoga. It is okay to like a bit of a challenge but if every pose is challenging and you are having a difficult time keeping up with the rest of the class, then it is time to change classes. I recommend that you discuss your concerns with your current teacher and if this isn't possible, like it is a gym yoga class, then I recommend you find a class where you can get more individual adaptations to your  physical abilities. It also sounds like maybe you are a bit bored in your class and the routine may be very predictable, so perhaps you might want to try some other forms of yoga that encompass the whole of the physical spectrum.

—Shari

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Friday Q A December Book Release

Q: I hear you've finished writing your book on yoga for healthy aging. Is it available yet? And how can I get a copy?

A: Although we've finished writing the book itself and taking all the photographs for it, the production period for a book like this is actually quite long. So, no, the book is not out yet. And although our original release date was going to be sometime in the fall, the publishers have decided to delay publication until December, the gift-giving season. So now our official release date is December 12, 2017. Here's a sneak peak at the cover design!

Don't worry, though, when the release date approaches, we'll be sure to announce that the book is finally available along with information about how you can buy a copy. 

If you are interested in hosting a book party or event at your yoga studio, please let us know.

—Nina

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Friday Q A Yoga for Long Distance Runners

Strong Winds, Pontoise by Camille Pissarro

Q: One of my running buddies sent this article to me that suggests that speed and strength training do more for injury prevention than stretching and I don't buy it. Part of my argument is that stretching feels so good :) I'd love to know your thoughts that I can share with my running group. I think strength and speed definitely build the muscles and make them stronger, but its all yang, yang, yang!

A: The article our reader is referring to is Impact of Stretching on the Performance and Injury Risk of Long-Distance Runners, a review article from 2015 that looked at all the available research on the effect of stretching on different aspects of endurance runners. The authors of the study were interested in finding out if stretching had any positive or negative impact on performance, if it improved recovery from post running soreness, and if it decreased the risk of distance running injuries. Because most research to date has focused on static stretching, usually with holds for 30 seconds, and very little on dynamic stretching, this study focused on reviewing studies that looked at static stretching. What they found might surprise many of us who that assume stretching—from yoga or otherwise—would provide benefits in all those areas. But it turns out this was not the case.

Regarding the first question, stretching done just prior to running actually had negative effects on performance! And although stretching done at other times was not found to have any significant impact either way, the authors noted that a certain amount of stiffness in the hips and calves may actually confer better long distance running ability than being more flexible. They recommend not stretching just before running or at all. 

Many distance runners suffer from something called DOMS, or delayed onset muscular soreness, a condition of muscle soreness that can last a few days after longer runs, which can be temporarily disabling. It had been proposed that stretching may decrease the intensity and length of this condition, but the research reviewed in this study showed no effect from regular stretching on this condition. 

It has also often been proposed that regular stretching might reduce the risk of overuse injuries in long-distance runners, such as Achilles’ tendonitis, plantar fasciitis, or IT Band friction. But, again, the research showed no significant impact on injuries with regular stretching regimens. 

With three strikes against stretching, you long-distance runners out there might just give up on stretching altogether and by extension asana practices that focus more on flexibility. However, despite these three specific cases, I would propose that there are additional potential benefits to a well-rounded yoga practice for long distance runner that still includes some stretching. The investigators did make one interesting comment that is relevant: 

“As a result, unless stretching possesses other health or performance-related benefits, it appears to have little purpose in an endurance runner’ s preparation.”

If we were to assume that a certain amount of stiffness in the hips and calves gives long distance runners an advantage in performance, we can easily design yoga practices that honor that, while still stretching other areas of the body that will benefit from improved flexibility, such as the spine and upper body. And I have noticed that despite being aerobically fit, runners often have poor overall posture. So a yoga practice could focus on improving posture as another goal, which will benefit you on and off the road. (We have written about the benefits of good posture in Friday Practical Pointers: Your Posture Affects Your Breathing and  Cultivating Healthy Posture with a Simple Restorative Pose.)

And Nina has reminded me that practicing yoga for healthy aging is not the same as practicing yoga for improved performance in running. If you completely neglect flexibility practices your whole life in order to improve your running, you risk suffering from loss of agility and ability to balance (not to mention the ability to move through daily activities with ease) when you’re older. So it makes sense to balance your strength building with some flexibility practices so you don’t become super stiff with age.

Finally if we look beyond the limited focus on flexibility and stretching, there are many ways a well-rounded yoga practice can support those out there who love there 5K’s, 10K’s and beyond. The improved mental focus and internal awareness you achieve from pranayama and meditation could actually help performance—professional athletes report this regularly after adopting yoga practices. Restorative practices could improve recovery times in regards to energy and overall tissue healing. And, of course, static strengthening poses for the hips and legs could support strength and maintain the right amount of stiffness in calves and hips that competitive distance runners may want to preserve. 

—Baxter

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Friday Q A Yoga After a Colonoscopy

Supported Reclined Cobbler's Pose (Supta Baddha Konasana)

Q: I have a question that may impact more than just a few of us baby boomers. I absolutely LOVE my yoga practice and am worried about how much I will be able to do after a routine colonoscopy scheduled later this month. After my last colonoscopy ten years ago, I experienced abdominal pain for several weeks. If that happens again, is it better for me to discontinue yoga until I feel better or are there just some poses I should avoid? Thanks for any advice you can give me.

A: Before diving into my recommendations for yoga practice after a colonoscopy, I thought it wise to talk about colonoscopy and what it entails. Knowing a bit more about this will allow you to get a better understanding of the typical effects of the procedure for most people. A colonoscopy is a specialized examination of the lower part of your digestive/elimination track, from the rectal opening at the pelvic floor, up through the “S” shaped sigmoid colon, up the left side of the colon proper (known as the descending colon), across the mid-portion of the colon (known as the transverse colon), and finally down the right side of the colon (known as the ascending colon). The colonoscope, a specialized device used for the colonoscopy, is tubular like a snake, a bit larger in diameter than a doctor’s stethoscope tubing, and long enough to make through the entire length of the colon. It is fitted with a camera at its tip, as well as an opening for threading a wire that has special tips on it to cut and retract tissue samples, and even to heat up tissue to stop bleeding. 

Colonoscopy was coming into its heyday when I was going through my medical school training in the early 1980s, and at that time it was recommended for anyone over 50 as a screening tool for colon cancer. Things have shifted since then as researchers have had more experience with the procedure and looking at who really benefits from such screenings. Nowadays, the colonoscopy procedure is less frequently used as a screening test, but some people will still have it recommended if they have a strong family history of colon cancer or microscopic blood detected on the home screening test most adults are asked to do annually after the age of 50. It is also used to diagnose persistent colon symptoms, especially pain, and abnormal bleeding.

Before the lining of the colon can be viewed successfully from start to finish, you have to clean out what normally hangs out in there! So, you will need to take liquid medication the day before the test to promote full emptying of your lower bowels. Occasionally, enemas are also needed to get things really cleaned out. The test is then done in an outpatient setting; after sedating you, the doctor will proceed to insert the device up into your colon. One problem still remains: the colon will simply collapse around the scope without something to keep it more open. So like blowing up a balloon—one of those long ones the clowns use to make hats for your kids—air will be blown slowly and carefully into your colon to stretch it out enough that a good view can be seen in all directions by your doc. And this is usually were patients will have a problem.

You see, you can touch the colon from the outside, as when having open surgery done, you can cut it with scalpel, or you can burn/cauterize bleeding blood vessels in the colon, and the colon will not register pain or discomfort. But if you distend the colon from the inside, as the doc is doing by introducing air into the colon, the colon will send messages of pain, discomfort, cramping, and distress to the brain, which you might experience after you’re out of anesthesia. Everyone’s tolerance for this is different, so some will not notice much and others will notice a lot.

If you have a lot of post-procedure symptoms like our reader, how should you approach your yoga practice? We know from studies on one particular kind of GI condition, irritable bowel syndrome (IBS—see Irritable Bowel Syndrome and Yoga), that yoga practices can have a beneficial effect on the gut function. A big part of this may be the stress-reducing effects of a regular asana, pranayama and meditation practice, but there could be more to it than that. It may be that in post-colonoscopy abdominal pain the gut’s unique nervous system, the enteric nervous system (see The Digestive System and Yoga), is triggered and on high alert, contributing to the persistent pain symptoms. Through the yoga practices that quiet the autonomic nervous system generally, you may also be able to bring the enteric nervous system back into quiet balance, resulting in a decrease in pain.

As for specifics, I’d recommend the following, which you could even start to do a week or so before your procedure, as well as afterwards:

1. Focus on gentle, quiet yoga sessions until the pain resolves.
2. Keep deep forward bends, deep backbends, deep twists, and side bends to a minimum.
3. Practice supported poses that encourage a gentle expansiveness in the belly in a slightly upright position, which encourages stuff in the colon to move down and out, on a daily basis, if possible. These poses include Supported Reclined Cobbler’s pose (shown above), Supported Savasana (shown below), Supported Reclined Hero Pose (Supta Virasana), and Supported Reclined Seated Crossed Legs Pose (Supta Sukasana). In all these poses, make sure that your torso is propped up higher than your hips, and add a little support under your head as well.
4. Incorporate mindful breath awareness, relaxing breath techniques, such as 1:2 ratio inhalation/exhalation pranayama, and guided meditations with a focus on overall body and belly relaxation into your practice.
5. Add an easy walk for 15-20 minutes a day, in nature if possible, to your yoga as part of your stress management, as your belly pain permits.
6. Communicate regularly with your GI doctor about your progress and your use of yoga along with their recommendations for treatment of your abdominal pain.

A compassionate, gentle approach to your yoga practice will not only keep you practicing regularly during this potentially difficult period, but may also speed your recovery. If any of our readers have had beneficial experiences with this in the past, please let us hear your stories.

Supported Savasana

—Baxter

P.S. Check out my video of how to practice Supported Reclined Cobbler's Pose:

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Friday Practical Pointers Changing Your Relationship with Pain

by Baxter and Nina

Jim Coughlin, Age 60

Those of you with health conditions or injuries that have resulted in ongoing, chronic pain or intermittent pain, (think low back injuries, fibromyalgia, and chronic migraine headaches, to name just a few) may have developed a certain adverse relationship with pain over time in the form of feelings of anger, fear, worry, anxiety, despair, sadness, or loss. Unfortunately these responses to pain will often trigger your stress response, which typically increases your pain. And brooding about the pain in general can increase your perception of your pain levels, something we call “the pain on top of the pain.” 

In addition to allowing you to actually reduce your pain levels (as your pain reduces, your attitudes and feelings toward it may also shift), yoga enables you to actively change your adverse relationship to pain in the following ways: 

1. Because brooding or thinking excessively about your pain can distort your accurate perception of your true pain levels, using yoga stress management techniques to quiet your mind allows you to short-circuit your mind’s tendency to focus on pain. In your new, clear state of observation, you may discover that your true pain levels are lower, sometimes significantly, than the pain you experience while focusing on it. 
2. You can improve your pain tolerance by listening to your body and improving your overall self care. You can also improve pain tolerance by cultivating mental and emotional equanimity, which enables you to be more content with what you have and what you don’t have. 

The following sections provide details about how to use this techniques.

How to Quiet Your Mind While in Pain 

To short-circuit your tendency to brood about pain, use any stress management techniques that work for you. We particularly recommend:

• Breath Awareness. Repeatedly coming back to your sensations of breathing interrupts your thoughts about pain 
• Structured Breath Practices. Simple breath practices that require concentration, such as timed 1:1 or 1:2 inhale/exhale patterns and alternate nostril breathing, keep your mind focused on your breathing. 
• Guided Relaxation. Recorded or self-guided relaxation practices keep your mind engaged on physical relaxation or positive imagery. 

As you practice these techniques, your pain levels may decrease, your tolerance for pain may improve, and your typical mental-emotional responses to your pain may become less intense or may even dissipate. 

In addition to quieting your mind, meditating on positive emotions, such as gratitude or joy, or on positive images, enables you to transform feelings of sadness, frustration, fear and anger into more positive states of mind. One study showed that meditating on joy literally activated the areas of the brain that produce positive emotions. This surge of positive emotions may reduce your pain levels, while also improving your pain tolerance and your attitude about the pain.

Meditation also has the long-term benefit of teaching you about mental habits that might be contributing to your pain, allowing you to consciously choose new, healthier ones. For example, your chronic pain may have triggered stress eating, which led weight gain that is worsening your pain (which can happen, for example, with knee arthritis). By observing your thoughts during a meditation practice, you may become aware of the chain of events that leads to your stress eating and then choose a healthier response to the pain, such as taking a short movement break that actually lowers your pain, rather than turning to food. 

How to Improve Your Pain Tolerance 

Mindfulness practices where you focus on your physical sensations other than pain, such as meditation, breath awareness, and mindful practice of asanas, allow you to tune into your body and recognize its needs. These practices teach you to differentiate between chronic, low- level pain and acute surge in pain, which will allow you to have a better sense of when to exercise and when to rest, of how far you can safely move in various yoga poses, and of which practices actually help your pain. (Of course, If your pain becomes severely acute and disabling, it would be wise to get to your doctor urgently.) 

Tuning into your physical sensations will also allow you to improve your self-care in general, as you, for example, realize you need more sleep or to schedule a health care treatment. Becoming an active participant in your self care can give you a sense of control, which can help you move past your adverse relationship towards chronic pain And improving self-care may even allow you to start participating more in the activities that matter to you, improving your overall quality of life.

Another way to improve your pain tolerance is to cultivate equanimity, the original aim of yoga:

When a man has mastered himself,
he is perfectly at ease in cold,
in heat, in pleasure or pain,
in honor or in disgrace. —Bhagavad Gita 

Studying yoga philosophy provides you with an alternative way of thinking about your life, enabling you to be more content with what you have and what you don’t have. And that includes accepting chronic pain as part of your life, which allows you to tolerate the pain more easily. In general, cultivating contentment as described in sutra 1.33 Patanjali’s Yoga Sutras, can be very helpful. 

1.33 Through cultivation of friendliness, compassion, joy, and indifference to pleasure and pain, virtue and vice respectively, the consciousness becomes favorably disposed, serene and benevolent.

Another particularly helpful technique for countering the negative reactions of your mind is pratipaksha bhavana, which means “cultivating the opposite.” 

3.3 When disturbed by negative thoughts, opposite [positive] ones should be thought of. —Swami Satchidananda 

Here’s an example of how to apply pratipaksha bhavana: If you had an increase in pain, your first thought might be, “I won’t be able to go to work today with this level of pain.” But practicing pratipaksha bhavana could allow you to reframe this thought to, “I will be able to work today, despite this pain level” or “Let’s see if I can work today, despite this pain level.” See Cultivating the Opposite for more information on pratipaksha bhavana.

But any yoga philosophy that speaks to you and helps you cultivate balance and equanimity in your mental and emotional life is going to help you increase your pain tolerance and improve the quality of your life.

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Friday Q A Hip Pain and Skiing

Q: I commented a while back on being old and having bad hips, but that was just basically a whine about pain. Now I actually have a real question. Last week I went downhill skiing in two feet of thick powder snow (very hard skiing). At the end of the day my hips felt great. Thighs and calves were pretty sore, but hips felt better than they had for ages. I think that this was the result of exercising each side equally—it was the only way to get through the powder without falling. How can I make sure in yoga practice that I am actually exercising each side equally? My teacher points out that each side may feel different in an asana, but that is usually the end of that. I understand that opposing body parts often "feel different" but is this a situation that we are not supposed to attempt to fix? I feel a great imbalance between right and left sides. Especially in the hips. What to do?

A: Your observation about symmetrical exercises making your hips feel better is very astute. Yoga is asymmetrical and that can be problematic for certain orthopedic issues. I am not a skier but what I can imagine is that the movement comes from weight shifting with the hips in a non-moving, weight-bearing position with the knees flexed and the ankles fixed within the skis. This position causes significant isometric muscle contraction to keep the joints stable. Muscle contractions increase blood flow to the area significantly, and if you had good alignment in your ski position, then the weight bearing forces were also nourishing the joint cartilage because of the increased blood flow. Proper alignment, with significant muscle contraction through all sides of a joint for a significant time period is what nourishes arthritic joints. You also did this activity for a SIGNIFICANT time, not just a 1.5 or 2 hour yoga class, which is not non-stop movement. Proper alignment, with significant muscle contraction through all sides of a joint for a significant time period is what nourishes arthritic joints!

So how to apply this to asana practice? One way might be to concentrate on “co-contraction” of opposing muscle groups when you are in standing poses, as well as in seated positions, inversions and backbends, that are specifically targeting your hips. Focus on activating your hip abductors, hip extensors, hip flexors, and hip adductors. Finding neutral in your hip joint before moving into an asana is also critical. Move your leg to a position without too much internal rotation or too much external rotation but balanced between the two extremes. Once you are in the pose, focus on isometrically contracting all the muscles that help you stabilize. Timing the sides also can be important, with a full 30-45 seconds on each side (use a kitchen timer as this time may be actually longer than you think). I would also recommend being careful to avoid pain in your hips going into or out of asana because this just increases the inflammatory response and causes more wear and tear on the joint cartilage.

—Shari

A: My take on this is a bit different than Shari’s, so you’ll have to try both of our approaches to find out which is best for you (and your hips).

First off, it would be helpful to know more about your hip pain prior to this glorious curative day of hard skiing. Which hip hurts, which movements have been aggravating in the past, and how has your yoga practice impacted the typical course of your hip pain?

I have skied and also skied in powder, and although you have to work harder to get through powder conditions, there is actually much less joint impact than in usual conditions, as the powder softens each thrust of the ski into the hillside. So in one sense, you might want to see how your hips respond to normal ski conditions But, of course, be careful.

Also, there is a balance between external rotation of one hip as the other hip internally rotates, in order to keep your skis parallel as you cut side to side on your downhill trip. Rarely are your hips in neutral for very long. In addition, you are in constant movement at the joint, not only with the rotational movement of the joint, but with the flexing at the hips and knees that increases and decreases moment by moment. This dynamic movement is different than some yoga practices, which have a held static quality, as in the Iyengar system, as we have discussed in the past. And this dynamic movement may be a better type of way for you to work with your hip.

Although the joint is in constant flux while you are skiing, the overall muscle tone around the joint is consistently engaged, so you are not relaxing into the joints and letting the muscles be more passive. This may also be providing more support around the joint than say in Pigeon pose forward bending version, for instance.

How does this translate to your yoga practice? Well, first off, you may want to work on dynamic mini vinyasa flows that partially replicate your experience on the mountain. You may want to work with a local teacher who also skis in order to create some personal movements for your unique situation. And notice if long-held, static poses aggravate your hip, as this may not work well for you long term.

—Baxter

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Friday Q A Can You Help Us

Hidden by Melina Meza

Q: Baxter and I would very much like to write a book on “Yoga for Healthy Aging” in the near future. And we’re betting that a lot of you would also like to see to a book on that topic by the two of us, along with input from our crew of regulars.

However, recent discussions with an agent and a publisher made us realize that these days publishers expect you to “bring your audience along with you.” So when you write a book proposal or pitch an agent, you actually have to give provide all your numbers, including your blog subscribers and numbers of hits, Facebook followers, and so on. And while we love all the subscribers and readers that we already have, we both feel our blog has the potential to reach a much larger audience. Recently we received this lovely message from a reader:

"Just a note to thank you all at YFHA for the helpful content you publish; it's no understatement to say that your site is, I feel, one if the top five yoga resources on the web - a true hidden gem."

So how about it, dear reader? If we promise to continue being a “gem,” will you help us out come out of hiding and find a larger audience for our blog?

—Nina

A: If your answer is yes, you can help by trying to get as many of your family members, friends, students, coworkers, etc. turned on to the blog. You can do this by sending email links to our posts and sharing links on Facebook and Twitter, asking the people you’re sharing with to do the same. If you’re a yoga teacher and it feels right to you, talk about our blog to your students and encourage them to become subscribers.

Finally, we’re open to your suggestions! So if you have any ideas, let us know either by commenting on this post or using the Contact Us tab at the top of the page.

(We have already outlined the book by the way, and we’re both feeling pretty excited it!)

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