WAWADIA Update #5 /// “First Do No Harm”: an M.D. on Asana-Related Injuries

Doctors and yoga teachers have the same first principle: Do No Harm. If we do things blindly, and if we don’t mine data, we won’t fulfill that principle. — Dr. Raza Awan

 

What I love about listening to Dr. Awan talk about yoga injuries is that he has all the relaxation of someone with no conflict of interest. He’s the medical director for Synergy Sports Medicine in Toronto, so he can show up for an intense yoga injuries discussion forum on a Thursday night, drop some data-bombs, and go back to work on Friday morning like nothing happened. Meanwhile, the rest of us yoga teachers wake up wondering what we should do next.

I can say this: he inspires to me move forward as if I have nothing personally at stake in this difficult discussion. But I do. How do I report to the yoga world I’m so invested in, to which I owe my livelihood, and that I spent over a decade teaching in, that several basic staples of asana practice might be definitively unsafe?

In an incisive comment to my last post, Adam Grossi criticized my rejection of “faith” in yoga discourse as being both reductive and dismissive of the “possibility that the practice is operating on us in a great many ways, while we may only be consciously aware of a few of them.”

So I’ll eat some crow here: I find myself moving forward on the faith that we’re all practicing enough to be able to take an honest look at what the tissue specialists are saying about how much we forward-fold, how much we practice, how repetitively we practice, and whether there are whole swaths of the population that do not need the enhanced flexibility that asana privileges while they paradoxically serve as the body models for the entire culture.

Here’s Awan’s presentation from the 5/29 “What Are We Actually Doing in Asana” gathering at 80 Gladstone. I’ll recount his key points below, interweaving some of my own commentary, in red italics. Please note that I am not commenting as a medical professional, but as a long-term student and teacher.

 

The Intro:

• Awan has been teaching yoga injury prevention since 2011. He got into it because he’d been sending patients to yoga classes for movement rehabilitation, but soon discovered that they were coming back to him with new injuries. This put him in violation of the Hippocratic Oath: “First do no harm”, which he’d assumed was also a foundational idea in yoga, vis a vis the principal of ahimsa. From there, he embarked upon his present project: to help yoga fulfill its therapeutic promise, in which he strongly believes.
• He describes wanting to approach Diane Bruni, his yoga teacher at the time, to discuss his research into yoga injuries. At first he felt intimidated, knowing that he was going to be asking some very challenging questions about a practice to which she’d dedicated her life. But he found her to be receptive.
• Diane explains that several years prior to this meeting, she wouldn’t have been open to Raza’s ideas and questions. But since having recovered from a severe hip injury herself, she wanted answers as well.
• Caveat: the rate of injury among yoga practitioners is not higher than for those engaged in any other sporting activity. For instance, 70% of runners are injured every season, and the percentage is higher for basketball players. Nonetheless, if people are attracted to yoga to improve their health and well-being, a preventable injury that sidetracks them from their goals doesn’t help anyone. Also — many physicians who recommend yoga to their patients are under the impression that yoga is a gentle exercise that would be appropriate for older or overweight patients.
• This lack of awareness amongst physicians of how rigorous asana practice can be may be a direct result of the success of yoga marketing in projecting an air of relaxing holism. Some forms of practice harmonize with this description, but many do not.
• The first patterns Awan noticed were repetitive stress injuries resulting from common movements and postures within the ashtanga-vinyasa category of practice. He began wondering whether if some general injury mechanisms were identified, the injuries themselves could be reduced through better education of teachers and teacher-trainers.
• The data in this presentation is culled from 75 case studies of yoga injuries, which is a pretty good sample, and will be more instructive than what we see in the scant research that’s been done so far.
• Here I think it’s important to note the obvious fact that Awan is reporting on patients who were willing to come to a biomedical practitioner and presenting a yoga injury. I have no statistics to support me here (and wouldn’t know how to generate them), but I imagine that this sample overlooks a large yoga demographic that is unwilling to see a biomedical specialist except in dire circumstances. In my many years in yoga culture I’ve known scores of colleagues who would exhaust every method of complementary and alternative medicine before entering a medical clinic. I was once of this mindset as well. My point is that his sample may be representative of the types of injuries that occur, but it likely also consists of that small proportion of injured yogis who would be willing to appeal to him as their primary support. There’s nothing wrong with practitioners using CAM to aid in the healing process, or in using nothing at all as the injury heals itself. The problem is merely that the CAM network is less disciplined in case study recording and collation, and often has no access to the most definitive diagnostic techniques of conventional medicine, such as advanced imaging. Injuries that heal on their own, of course, cannot be counted.

 

The data:

• The sample consists of 70% women, 30% men: not surprising.
• Average age: 40
• It’s worth noting here that injuries are likely occurring more frequently in the approach to middle age. While this is not surprising in itself, it makes me wonder about the impact of the majority of asana teachers today being under 35.
• Most commonly affected body part: lumbar spine, 40% of the sample. Disc herniations, disc bulges, sciatica. Many resulting from over-application of forward folding. Awan notes that lower back injuries “take months and months” to heal.
• Awan had assumed that these lower back injuries would mainly occur in men with tighter hamstring muscles who would be forced into stronger spinal flexion. But women classified as “hypermobile” were most prone to lumbar injuries. He discovered that these practitioners had often been encouraged by instructors to push into and beyond the end-range of their motion.
• 20% of the sample featured knee injuries involving torn cartilage, most taking 6-8 weeks to heal.
• 15%: shoulder injuries, most common in women doing arm-balance poses.
• 10%: neck injuries from headstand and shoulderstand.
• Of the sample, 20% of injuries were sustained by yoga teachers. Awan remarks that coaches for basketball, volleyball etc. should know the mechanisms of injury for their sports and should know the proper techniques for avoiding them.
• I believe this is not representative, because my sense is that many yoga teachers are even more resistant to biomedical care than average yoga practitioners. Many teachers are quite invested in the idea that yoga practice will heal the injuries that come from practicing yoga.
• The fact that 20% of his sample are yoga teachers leads him to infer that a main mechanism of injury is overuse. 
• Awan refers to Diane Bruni’s report of having practiced for 3 hours daily, six or seven days per week — which is not unusual for many dedicated teachers — and notes that if she’d done any other intense physical activity like running or playing basketball for that amount of time every day, she would be injured as well. Overuse is compounded by repetition, using the same muscle groups and actions, day in and day out.
• See Kathryn Bruni-Young’s comment on this narrowness of focus.
• 45% of injuries featured an increase of yoga practice as an onset condition.
• 25% of injuries came from beginning teacher training.
• 3% of injuries came from from harsh adjustments.
• This last statistic does not jibe with my interview research of 60+ practitioners so far. I believe that the rate of injury occurring through adjustment is much higher, and possibly underreported because of fears of interpersonal or even legal conflict.
• Awan recounts, somewhat disbelievingly, the story of a hypermobile patient who was injured when a teacher stood on her back with both feet.
• I think the good Doctor is perhaps unaware of the ample video footage of several of the founders and central teachers of MPY doing exactly the same thing.
• 40% of injuries were sustained by those who were practicing 3x per week or more.
• Poses most likely to cause injury: forward bending in either standing or seated positions. Featured in 40% of recorded cases. This is an essential movement in several postural vocabularies.
• 10% of injuries were incurred through backbends.
• 10% of injuries were incurred through rotations.
• 7% of injuries were incurred through arm balancing.
• Typical high-risk postures: pigeon, headstand, arm balances, arm binds, lotus, warrior one, crow, shoulderstand.
• Awan recounts an outlier story of a thin male practitioner who lost control of his wrist and hand after performing an arm bind that compressed his radial nerve. Awan says that he’s beginning to see other nerve injuries that come from poses that apply prolonged pressure.
• In his training sessions for YTT programmes, Awan has been working with his colleague Riki Richter to present the injury mechanisms behind certain poses and then teach safer biomechanics approaches.
• Awan acknowledges that class size is a factor in preventing teachers from clearly addressing each instance of risky behaviour.
• He wonders aloud whether headstand and shoulderstand should ever be taught in level one classes.
• He wonders aloud whether hypermobile and non-hypermobile students should be in the same classes at all. Classes for the hypermobile could focus primarily on strength training, and not put them at risk in by encouraging end-to-range-and-beyond stretching.
• He wonders aloud whether any fixed set of asanas can be healthful, and whether a series should be changed for those who practice 2 or more times per week.
• He finishes with a reiteration that despite all of these data, he still believes that yoga asana is a very helpful practice, but that it would benefit from dialogue with the medical community.

 

Addendum:

I’ll write more about this in an upcoming post, and much later in the eventual book, but I wanted to briefly address two issues that have come up in relation to this general discourse on injuries. One commenter on a Facebook thread had this to say about the notes that I delivered on 5/29:

Yet another voice encouraging personal responsibility in asana practice. Most of this video describes individuals who have ignored what their own bodies are telling them, yielding responsibility to some half-baked advice from a yoga instructor or a yoga philosophy taken out of context. The examples he cites seem to come from those who confuse a physical asana practice focused on ever-increasing levels of flexibility, with yoga.

Setting aside the implicit victim-blaming here, as well as the willingness to decide who is and isn’t doing “yoga”, this is a misinterpretation of my position. Personal responsibility is always important, but the research so far is actually calling for much more than that. The injuries cited were provoked by a number of factors, only one of which involved the goal of increasing flexibility. Other factors include the poor biomechanics training of the instructor, invasive/assertive attitudes in adjustments, and a general pressure to “go deeper”.

Even more problematic is the fact that many injured yogis have actually been listening to their bodies, but have either sublimated or rationalized pain according to prior training or present encouragement. (Or they might also have compromised nociception.) It’s becoming clear that instructors who think that telling a student to “listen to their body” is adequate for preventing injury are simply wrong. Our neurology and psychology have too many built-in workarounds for pain for this to be sufficient advice. Confusingly, some of these very workarounds can be inflated by appeals to philosophy, etc. I think the bottom line is that teachers must learn to listen to their student’s bodies along with them. Less than this can involve blaming the student. It’s helpful to remember that medical professionals do not rest on invoking personal responsibility alone. As Dr. Awan pointed out later that evening that his governing body — the Ontario College of Physicians and Surgeons — levies severe penalties for malpractice.

The second and related issue was raised by a participant during the evening, and it’s familiar to me from dozens of previous conversations. It basically asks: Aren’t all of these injuries arising out of an ignorance of the non-asana aspects of yoga practice? Aren’t we getting injured because we’re uninterested in the ethics, attitudes, breath sensitivity and meditation practices of yoga?

I think the short answer is that practicing “non-violence” or “mindfulness” is not enough to protect people from injuring themselves. Moral and psychological principles do not translate into tissue-knowledge. There are thousands of practitioners who are extremely serious about the 8 limbs — lifelong vegans and meditators, for example — who have still been injured in asana practice, because their biomechanics training is insufficient. In the meditation world, there are countless examples of practitioners who injure themselves by meditating on non-violence! Practicing with these ideals in mind is doubtlessly helpful, but it will not stand in for qualified training.

Finally, we must consider the argument from some practitioners — as expressed in this recent post from David Garrigues — that asana in and of itself encapsulates all other modes of practice. This belief is resonant with centuries-old haṭhayoga notions that physical practices should precede the intellectual consideration of morality, etc., lest immature or disembodied understandings contribute to the psychic pressures that suppress the flow of kuṇḍalinī. (For more on this, see Swami Muktibodhananda’s commentary to the HYP.) It’s an argument that would seem to make it even more important that asana be practiced in as safe and nurturing way as possible.

Between those who say that MPY has lost its way because it doesn’t adhere to ancient philosophy, and those who say that asana done properly contains its ancient philosophy, the need for improved biomechanics education and more informed pedagogy clearly remains.