fishmansaltonstall yogaforbackpain2 transcriptpartone
TRANSCRIPT
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Yoga for Back Pain:
Keys to Safely Preventing and Relieving Back Pain
A Yoga U Online Course
with
Dr. Loren Fishman and Ellen Saltonstall
Transcript, Session 1
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Eva Norlyk Smith: Hello, everyone. This is Eva Norlyk Smith with Yoga U Online.
Welcome to session one of our two-part course with Dr. Loren Fishman and Ellen
Saltonstall on Yoga for Back Pain: Secrets to Safely Preventing and Relieving Back
Pain. I am very pleased to welcome back popular Yoga U presenters, Dr. Loren
Fishman and Ellen Saltonstall. Dr. Loren Fishman and Ellen Saltonstall are
co-authors of several books on the therapeutic use of yoga including Yoga for
Osteoporosis and Yoga for Arthritis. Dr. Loren Fishman specializes in physical
medicine and rehabilitation, and he has been using yoga as an adjunct therapy in
his medical practice for more than 30 years. In fact, Dr. Fishman is such a pioneer
in the use of alternative approaches to back pain and other chronic pain issues that
his work using yoga as therapy in his medical practice was profiled by health writer,
Jane Brody in the New York Times a little while back.
Ellen Saltonstall is an author and works as a yoga therapist in her studio in New
York City. Ellen has a vast background in movement therapy. She holds a masters
degree in the field of therapeutic movement education, and shes a senior teacher
of the kinetic awareness program for myofascial release. She is particularly
renowned for her work using yoga programs for repetitive sprain injury,
menopause, shoulder issues, sacroiliac joint, and many other topics. Ellen is
particularly regarded for the depth and specificity of her teaching. She also teaches
yoga group classes as well as individualized therapeutic yoga sessions at her New
York City yoga studio. Loren and Ellen, welcome.
Dr. Loren Fishman: Thank you. Tonight well be talking about yoga for lower back
pain. And the first thing Im going to do, of course, is I recommend you do with all
your patients and your students is to know that there are danger signs. I want you
to be aware of these because perhaps the most important thing you will ever do is
say to a patient, I cant help you. You got something very serious. Dont even put
on your leotard. Lets go to the hospital. Those signs are what we call the cauda
equina syndrome that every nurse or physician will understand immediately. The
danger signs are when there is ascending numbness (numbness starts in your feet,
it starts going up to your ankles and your calves), ascending weakness (the same
sort of trajectory), bowel and bladder changes (suddenly, Oops, my goodness, hes
wet!), or very severe pain. Very severe pain all by itself does not constitute cauda
equina syndrome, and you can probably over diagnose this much more than
underdiagnose this, but it is there. And when people are complaining of these
things, you must then recognize it is an emergency. You may be wrong. It may not
be cauda equina but to tell them that it is when it isnt, is far better than
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telling them it isnt when it turns out to be. Its quite rare. A study shows its one in
a million in the population, but that doesnt mean you wont see it over the years. I
just want to point it out to you because you can save somebody not their life but
their happiness, their lifestyle. They become paraplegic, they lose control of their
bowel and bladder. Its not good.
Lets go on a little bit. When you see patients or clients (whatever you call these
people that have back pain), you can divide your pain into two categories very
easily. Is it acute? Are they coming to you because their friend said, Oh, I know
somebody who treats that, and no one else has seen it? Those are cases where
you have to make the diagnosis. Nobody knows what it is. It may be very deceptive.
It may be hip pain. It may be neuropathy. It could even be a terrible stomach ache,
honestly which makes their toes tingle. And it may get worse over time, a short
time, versus chronic which is what one is more comfortable seeing. Theres already
a diagnosis, you sometimes even know what works and what doesnt work, and the
whole thing is more or less predictable. They all have pain. Now whatever else pain
is, it raises awareness of itself and it lowers the persons concentration for
everything else including yoga, including talking to you. Once the yoga works a little
bit, they focus on it. They fasten on it like a leech. Theyre on there. They want
more yoga. In the beginning, though, its not that way. You have to gather their
attention by relieving their pain. To do that, the most important thing is to find out
what is wrong. In order to do that, you have symptoms like back pain, buttock pain,
sciatica, tingling, numbness, weakness.
Sciatica, all by itself, is not a diagnosis. Its a symptom like a rash. You got a rash,
but is it poison ivy, is it chicken pox, is it eczema; you dont know, you just know its
a rash. The same way with sciatica. You have pain down your leg, you know what
you feel, but what you dont know is, is it due to a herniated disc, is it due to spinal
stenosis, is it spondylolisthesis, is it piriformis syndrome? You really dont know. I
think thats one of the take-home points of what were saying today the same
symptoms may have several different causes.
Now here are the seven major causes. What does cause back pain? The rest of
what we talk about today and next week will be right here in these seven causes.
Dont write them down. Youll get sick of them by the time were done. Anyway,
here they are. I divide them up like this some are neurological, some are
musculoskeletal, some are a little bit of each.
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Well start with the herniated disc, the famous herniated disc, and well go to spinal
stenosis. And then well leave the strictly, purely neurological diagnosis. So lets just
go ahead. The difference between the neurological and the musculoskeletal one is
big. In the neurological one, you have paraesthesia, numbness, sciatica, weakness,
and then this problem with the bowel and the bladder, and some atrophy where the
muscles get small. Now what is a paraesthesia? A paraesthesia is sort of the
opposite of numbness. Numbness is where you dont feel something thats there
someone touches you and you dont even know. Paraesthesia is the reverse. Its
where you do feel what isnt there. You feel pins and needles or hot and cold or
strain or burning, or stretching when theres nothing doing the stretching, no
needles. So these are the things you feel, and the order there is absolutely from the
least serious to the most serious.
Paraesthesia, this feeling something that is not there is the first sign or harbinger of
something thats wrong. By the time you get to numbness, theres no question
about it. Pain is next, and then weakness, where theres muscular debility and then
atrophy where the muscles are actually wasting away in the bowel and bladder.
Neurological, thats what it is.
Musculoskeletal has none of this, no paraesthesia, no numbness, no pain down the
leg, no weakness, and no atrophy or involvement of the bowel and bladder. Rather,
theres tenderness where you touch it or point. Theres an ache, usually, rather than
a sharp electric-type pain. And the movements are often painful. So thats the basic
thing. Now could movements be painful with something neurological? Yeah, I
suppose they could, but this is the picture that you usually see. You have to be
ready in this to just shift your focus and say, Well, maybe its this, but on the other
hand, I can make a picture for the opposite, too. This is cerebral work.
So now lets stick with the neurological. On the left, you see exactly what you saw
before. On the right, you see the kinds of things that can make it happen the
herniated disc, spinal stenosis, and spondylolisthesis, where one vertebra is slipped
forward on the one below it. Doesnt it sound like slip spon-listhesis, listhesis? The
non-neurological, on the other hand, nothing no sciatica, no numbness, no
paraesthesia, no weakness. Hurts to the touch, hurts to move, can be acute or
chronic. The idea is you have to pay attention to it because thats a huge group, but
were not starting there.
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Lets start with the neurological. Lets talk about first a herniated disc. See the little
red circle there? Thats where it is. The pain usually emanates from that point
where the nerve comes out of the spine. Now is the pain there? Maybe yes, maybe
no. The pain may be way down there where that crosses in the middle of the calf,
that persons right leg. They may only feel that, even though the cause is way is up
high, the manifestation can be literally feet away.
What about spinal stenosis? Well, thats in the middle there, right in the spine. Once
again, though, the pain may be felt very far away, all the way down the course of
the sciatic nerve, or some other nerve.
Spondylolisthesis, thats the slippage of one spine on another and it can be on
almost any level in the spine.
Piriformis syndrome? Well, thats in the buttock where the nerve comes out. And
since its out there, theres almost always pain in the buttock even though it may
indeed go down the leg.
So those are the four big things that cause sciatica. If you put them all together,
you see all the different places that can cause back pain and sciatica. There are a
lot of them. Its hard to figure them out but here we go. How do you do it? Doctors
have ways that I want you to have, too. Theyre not so tough. All they demand is a
little common sense. They are the dermatomes and the myotomes. Tome means
cut in Latin. And so this is skin cuts and the muscle cut. Where do the distinctions
get made? Any questions at this point? Lets stop right here for a second.
Eva Norlyk Smith: I think clarifying spinal stenosis..
Dr. Loren Fishman: Good question. I didnt really say that, and thank you. Spinal
stenosis is narrowing of the spinal cord, the long vertical column from your brain all
the way down to wherever the nerves exit the spine. Well talk more about that
later. Thats a very good question. Well definitely go into that in much greater detail
than Im going into right now.
The dermatomes on the left there. Thats a very squat looking figure. Every part of
this body is served by a different nerve coming out of the spine at a different level
the front of the thigh there in brown, thats L2, the knee is L3, the inside of the
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Calf is L4, the dorsal part of the foot or top of the foot L5, the outside of the calf S1.
Those Ls are for lumbar, the S for sacral.
Now over on the right You can study this at home. Its in so many medical books.
And why is it there? Because its so important. These are the reflexes and which
muscles are involved in which. The thigh muscle, corresponding to the brown area
there (but Im not talking about the skin, Im talking about the muscle), thats L2, 3,
4; the quadriceps, the outside of the calf, even though its S1 in the skin, its L4, L5
for the muscles there. The inside of the calf, even though its L4 for the skin, its L5,
S1 for the muscle. It gets confusing. These are things you really should know. And
there are reflexes corresponding. Someone doesnt have a good patellar reflex,
thats the quads, thats L2, 3, 4, thats in trouble. Person cant walk on their heels,
that means its the anterior tibialis at the outside of the calf. Thats L4. You can
learn so much without a stethoscope, without an x-ray machine.
Here are the more advanced medical tests that you may need, and you may actually
ask doctors to do this. If youre interested in having a practice that you take care of
the kind of patients that doctors take care of, you must refer the doctors. Then
theyll know who you are, and theyll refer to you. Theres the MRI which gives a
structural picture of the soft tissues. Unlike x-rays that pass right through those
tissues, the MRI delineates anything with a different density, a different consistency.
It goes in different angles or all kinds of special effects. Theres no x-rays, all
magnetic. They do it on little babies and women in the eight month of pregnancy
and the first month of pregnancy. The only trouble with it is you cant move. You
move, you ruin the whole show.
EMG, on the other hand, in the right-hand box, is functional instead of structural. It
tells us which nerves are working, how do they work, and how well do they work. It
talks about nerves and muscles. You can do all kinds of different positions. There
are special tests for people that only feel pain in certain positions and you can move
a lot when youre doing it so you can actually get a dynamic picture of what works
and when and why.
Herniated disc, what about it? Well, heres what it is. It has a discreet onset usually,
usually. That is, I went over to my aunts and I lifted her refrigerator, and thats
when she got it. I was in a small car for seven hours and when I got out, I could
hardly walk, thats when he got it. Theres often sciatica. There are often changes
in sensation and that involves the numbness and paraesthesias we spoke about.
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Theres sometimes weakness, theres sometimes not. And it may or may not hurt in
the back. The cause is in the back, the manifestation may be way down the leg or
even in the foot.
Heres a picture of the spine way on the right and you can see my pathetic notions
to tell you which way that person is facing. Thats a little smiley pumpkin face up
there. The discs are in the front, the big bones associated with the vertebral column
are in the front, the nerves are in the back. You see where the neurological material
is? Its back further, and its protected. One of the functions of the spine (not its
only function), but one big function is to protect those precious nerves that are
coursing down through your body.
Now were cutting sideways, were taking a slice horizontally where that middle
arrow is emanating left on neurological which is slicing the spine and were taking a
look in there, a cross-section. A disc comes out from down below, from that gray
stuff below, and pushes upwards. The person is lying on their stomach and their
spine is sticking up in the air like the flaps of a dinosaurs back. This will press up.
Let me show you what the disc will do. It will press like that, right into the
neurological material. Or it will press off to the side, and catch one of those nerves
as it leaves the spine. Or it may do both.
What is it doing? Well, heres a cross-section of what they call a spinal unit, which is
two vertebrae and a disc and a nerve. And that red oval on the left gives you the
whole unit. Theres the nerve exiting. When the disc is herniated, it will press back
towards the nerves. Look at the figure on the right now. Thats a herniated disc
pressing against the nerve. The big yellow oval is the neuroforamen, the open
space surrounded mainly by bone. So if theres inflammation there, not much you
can do about it for that space to expand. Rather, it presses hard against the
vulnerable structures within the nerve. Heres a nice pose for that.
Ellen Saltonstall: So when the discs are herniated, you want to extend the spine
but very gently, and you want to make sure that you extend the spine with length.
So youre trying to make space between the vertebral segments, so that the disc
has room to have its proper place and not impinge on the nerves. So youre trying
to strengthen here your back muscles all the way up the spine from your head
through your upper back, through your lower back, and use the muscles to open
the front spine so that the disc can come back into its proper place.
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Dr. Loren Fishman: I just want to add, in a pose like this, Salabhasana, the
Locust, youre also strengthening the muscles of the back, youre lifting your legs
and your arm and your torso and your head against gravity. So youre getting better
at doing this.
Ellen Saltonstall: And usually, the disc will herniate when theres excessive
forward bending, like especially when he mentioned lifting someones refrigerator.
Youre forward bending and putting an awful lot of force, a high degree of force into
the spine and so, the herniation happens usually in that situation. So youre
teaching the spine how to be in better posture for any activity by doing this kind of
pose. Its a mild pose, because you really only have to lift a little bit off the floor.
Youll see some more poses coming soon where you do a little bit more back bend.
But its really important, I think, for yoga teachers to know that you can do the
correct action in a very small way for someone who has been injured, or is
recovering from disc herniation, and they can do it safely and thereby establish the
proper habits in their musculature.
Dr. Loren Fishman: This is one of my favorite early poses because, first, because
the person isnt going to go any further than they can go without hurting
themselves.
Ellen Saltonstall: Its self-limiting.
Dr. Loren Fishman: And yet, theyre strengthening themselves and actually
preparing themselves for more difficult things. Its really pretty safe. Osteoporosis?
Thats okay. Spinal stenosis is the only thing that might be a little bit of a negative
here, but well get into that in a while.
Ellen Saltonstall: Here are two other back bending poses, both of them using the
arms, which will help to moderate the degree of back bend. You dont want to have
someone back bend too forcefully or in too much of a range of motion right away.
So with the Cobra, you notice that he has placed his hands a little bit wide apart,
which usually increases peoples awareness of lengthening the spine. Often in a
class, youll see people do Cobra with the hands really close in, and it does constrict
the ability of the back to extend quite a lot. So I recommend doing Cobra with the
hands wider, keeping the shoulders back, avoiding thrusting the neck back, and
making the curvature very, very even all the way up the spine.
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On the right side, you see a modified Ustrasana so that the student has the support
of the chair, and can really work to lift the spine a lot. Generally, when you push
down with the part of the body like the arms and the legs in this case, then the
spine can lift. And thats really the curative action for herniated disc.
Dr. Loren Fishman: Now, theres a little trick here with the Camel Pose on the
right. By leaning back that way, you can get an arch. Some people think they can
get more arch by pushing their pubis forward, pushing their hips forward. But
actually, the way they usually try to do that is with their quadriceps. The trouble is
one of the quadriceps crosses the groin, so they cant do it that way. But a clever
way to do it is for a person to hook their feet across around the chair at the back or,
if theyre doing the regular Camel, to put their hands on their heels and push your
heels upwards so you use your hamstrings. And using your hamstrings will indeed
push your hips forward, and you get a much better pose. I wouldnt say it to a
beginner or one thats moderately into it. But as you get further into it, thats the
way to do the pose better.
Now were obviously going full bore. These are not simple things to do but theyre
wonderful things to do. These are more challenging. Let me show you how they
work as I put some slides in to show it. You can see Urdhva Dhanurasana, Up
Facing Dog, very well this way. Heres that herniated disc. We just talked about all
these poses. Heres the disc on the right there. You see its that part of the spinal
unit. On the left, it shows where it is. And theres that fluffy stuff pushed out of the
disc, pushed there and right where its not supposed to be close to the nerve. Well,
as you arch your back, you open up the front of the vertebrae. And like a bellow,
like opening a bellows, it draws that material back. It creates a partial vacuum and
draws that material back. Thats the way it works. Im doing it in a second, but it
may take several weeks or it may happen rather quickly. And thats the way this
pose works. Any questions now?
Eva Norlyk Smith: One modification that is often prescribed for people who have
problems with back bending like in Cobra Pose, Bhujangasana, (you had your pelvis
on a blanket), but one of the things thats often prescribed is to have your pelvis on
the blanket, but the pubic bone on the mat so that theres a little bit of a tilt to the
pelvis
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Dr. Loren Fishman: Thats fine. One trick with that is, although its hard to do
this, but if you soften your abdomen (which I think that method would promote
because you feel hard against your pubic bone and that blanket will be soft against
your abdomen), so if you soften your abdomen, then your abdominal muscles arent
pulling you out of the extension, out of the arch of the back. So softening the
abdomen, its a little hard to do because youre protecting all your internal organs
when youre lying that way but it works very well.
Ellen Saltonstall: And softening the abdomen does make the back bend more
productive.
Eva Norlyk Smith: There was a study that came out showing that yoga seemed to
help with degenerative disc disease. They did MRIs with a group of people and the
yoga practitioners had less signs of degenerative disc disease. So would that
indicates that yoga could help prevent not just disc herniation and disc issues but
possibly also other chronic back pain issues that come from the gradual
deterioration of the intervertebral discs?
Dr. Loren Fishman: Yes, its wonderful. I mean, I think it has to be verified. I
think one study isnt enough because thats really important. That is big news.
Thats a regenerative feature of yoga. Thats magic itself. Thats the fountain of
youth, the Holy Grail. I mean thats some really good stuff. I read the study and it
just has to be duplicated once or twice and theres nothing like that. Thats really
good stuff.
On we go with the spinal stenosis. What is it? Heres what it is. Its where the cord
itself, the drawing on the right side of the left part of the slide shows you where the
cord ends. When youre a little baby, your spinal cord goes all the way down to your
coccyx. You can see it in the little arrows, CNS, central nervous system, ends here.
But as you grow, your vertebrae grow faster than your nerves and outstrip them, so
your nerves retract upwards, up to the spine. And little long cords come down,
which on the right you see theyre called, by some fanciful anatomists, the horses
tail, the cauda equine. And they do look that way. Those are the nerves. Where are
they traveling? Theyre traveling in a hollow column that starts at the brain and
goes all the way down to the coccyx. And that hollow column is what gets narrow in
spinal stenosis.
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Heres a better view of it. Its a busy place. And when it gets narrow, its really hard
for all those nerves to get out there and they get irritated and all kinds of
inflammatory tissues and fluids arise there. And then theres pain. And when theres
extension, several cadaveric studies, mostly by PTs, show that extension will further
narrow the already narrow spine by more than fifty percent, up to sixty-three
percent. So if its already too narrow, extension is really not something you should
do. So Salabhasana, Kapotasana, Ustrasana, out of the question.
Now having said that, I have to make a caveat. About five percent of the time,
extension works for these people. I have a theory of how it works, but Im not
gonna tell you what it is yet. We have too many basic things that we do know to
talk about rather than to talk about speculative things. But about five percent of the
time, extension will work with spinal stenosis, and the same flexion will work with
herniated discs, exactly what otherwise doesnt work. So be tentative when you
start. Here are the poses that make sense for this. Look what a busy place it is.
Ellen Saltonstall: We have pictures of the various recommended poses here for
this spinal stenosis. In Downward Facing Dog, you can really stretch the spine
without diverting very much out of its neutral shape. In fact, you want to maintain
its neutral shape by arching your lower back, reaching your sitting bones up and
back, keeping the normal curves of the spine, while weight-bearing on the hands
and the feet. So its a very good strengthener and makes a good neutral position of
the spine that actually does a good elongation. And then in Vasisthasana youre on
your side. In the same way, the spine is in the neutral shape. Its not curving,
arching, twisting, and yet, its a very good strengthening pose.
Dr. Loren Fishman: In the pose on the right, I have to apologize a little bit. That
woman is actually countering scoliosis in there. Otherwise, she wouldnt be bulging
her left side ribs up that high.
Ellen Saltonstall: Here, we have a forward bend, Prasarita Padottanasana, and we
showed some modification so that its not too much of an extreme forward bend.
Im sure most of you yoga teachers know this already, but you can use a prop to
allow a person to extend the spine more truthfully while the legs are stretching.
Because many times, a beginner will be completely curved over in this pose, trying
desperately to reach the floor, trying to yank on their legs, and thats just really not
helpful in this kind of case. So you do use a prop to allow them to work more
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honestly and really stretch the legs, really move the sitting bones back and extend
the spine. So I like to use the props and even instruct to lengthen the ribcage and
just really get as much length through the whole torso as possible. And then when
someone progresses, of course, they can go further down. You see the variation on
the right with the blocks.
Dr. Loren Fishman: Theyre like training wheels on a bike. And when the child is
ready, you just take the wheels off and they ride away. These blocks and all of
these paraphernalia need not be there when you get pretty good at it. But how
many herniated discs have I seen and people fiercely and desperately grasping their
ankles and pulling for all their worth, pitting their muscular strength against their
stiffness, and nobody wins.
I just want to tell you something about Vasisthasana that you may not know. This is
an MRI of a person that has a herniated disk and spinal stenosis which you can see
pretty well down low in the spine. This is that same person. Look down at L4, L5.
Look how the whole vertebral column slid to the left and look at that disc pressing
against the white stuff which is where the nerves are, absolutely occluding the
white stuff there at the same level. And here they are in Vasisthasana. Where is it?
Wheres the spinal stenosis? Wheres the spondylolisthesis? Wheres the herniated
disc?
Heres looking at it cross section. Right in the middle there, you can see theres a
little tiny space, sort of a triangular space. Thats where the nerves are supposed to
fit. Now here is the same person, a minute later in Vasisthasana. See the
difference? Here they are not in Vasisthasana, and here they are in Vasisthasana.
Its amazing. There are a number of poses that are good.
Now well go on and talk about musculoskeletal illnesses. This is a great big vast
section. It goes on and on. Well just talk about a few of them. I said the most
important thing in my opinion already which, is look and see. You dont know what
it is until you look. And you will never see if you dont look.
Ellen Saltonstall: Posture makes a difference. You can see lots of different
variables of postures, so its good to be able to see clearly your students, what kind
of spinal posture they have. You can see the ideal posture in the middle and on the
left and on the right slide, to the far left. You want to look do they have too much
curvature in the upper back, too much curvature in the lower back, no curvature
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anywhere and all kinds of deviations left and right. So thats really important to
know about your spine if youre doing yoga and your students spine.
Dr. Loren Fishman: Now here, lets compare again and say if its spinal stenosis or
a herniated disc or spondylolisthesis where the spine is slid over, then if its
neurological. If its musculoskeletal (these are just three of the many candidates), it
could me muscle spasm, it could be sacroiliac joint derangement, or a facet
syndrome. When its musculoskeletal, remember, theres no numbness, no
weakness, no pain that goes down the leg, no atrophy, theres no bowel or bladder
involvement. There is tenderness. Theres some place you can press and the person
will go, Thats it. Youre not just being a brute. Youre getting to the spot where
the pain comes from. There will be aches, most likely, some movement or other will
be painful. Its eighty percent of all back pain. It is second in days of work missed
only to the common cold. And it is often spasm in relation to strain.
Many forms of spasm.. Lets just start with the one which I think is very common
the quadratus lumborum, that large quadrangular muscle that starts at the ribs
and goes down to the iliac crest. It gets tight. Ellen showed you in those profiles
where the back is too arched many children carrying their book bags, many adults
who just wear high heels too often, or its just their posture. Women, when theyre
carrying their baby, often will have very tight muscles there.
Ellen Saltonstall: These are all forward bends, obviously. Three out of four of
them have the arms forward. When you do that, you catch another muscle,
latissimus dorsi, which goes from the top of your arm all the way down to your
waistline and into the top of your pelvis. So you need to stretch all the way down
the back because the lumbosacral fascia, the tough coating of the muscles down in
the lower back, is very very tough. It takes some time to stretch. So these poses
would not be appropriate for someone with a herniated disc. And probably not for
someone with stenosis, either. But they are appropriate if you know that the
problem comes from muscular spasm.
We have Janu Shirshasana. We have Childs Pose, simple Childs Pose with head
resting on the hands. We have Triang Mukha Ekapada Pashimottanasana on the
lower left, and then a version of Malasana on the far right lower corner. I really like
this one for clients that I see because many people cannot do a seated forward
bend, or perhaps they cant even do Childs Pose because they have problems with
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their knees. So Malasana on a chair is very good because you dont require much
stretch of the hamstrings, a little bit but not very much And you get a major stretch
of the lumbosacral fascia, a major stretch of the latissimus dorsi, the quadratus
lumborum, and all the vertical spinal muscles, the erector spinae muscles that go up
the spine. So its very, very good for spasm.
Dr. Loren Fishman: I just want to say, can you see how to use this? If somebody
comes to you and says their back really hurts, you find out they dont have any
numbness, they dont have any tingling, they dont have any pain going down the
leg, theyre not weak, they dont have any bowel/bladder problems, the muscles
look altogether symmetrical, then its time to start these. You may not want to go
full bore all this far, but you may want to start with this. Start with one of these,
start with Janu Shirshasana and see if it helps a little.
Ellen Saltonstall: Well show you some easier variations of some of these, too,
that are coming along.
Dr. Loren Fishman: I mean, you could figure out there are easier versions. You
just do them halfway or a quarter and then you go further. Show them you care
and they will focus on your care, and focus on what you care about, which is them.
At times, a form of arthritis is facet syndrome, the joint that has really gotten out of
kilter. They sometimes call it the mulberry joint because it looks like a boiling up
mulberry. At times, its just spasm. You do an x-ray, you do an MRI, you do all the
fancy things, you dont see a darn thing, because the muscle is tight. And what do
you do for that? Well, what happens in this case, in either case, whether its arthritis
that crimps the joint from moving, or its a spasm that holds the joint fast so it
cannot budge, in either case, you want to work with it, you want to get that joint to
move.
Here is the mulberry on the right. On the left is a normal spinal unit. Theres that
little facet joint right in the middle there, slipping and sliding. But on the right,
theres arthritis. Theres a bump on the road. It doesnt move that way. Theres
speed bumps all over the place. So what do you do?
Well, let me explain just briefly that all the different levels of the spine, they all have
facet joints. But in each case, theyre different. Never mind the atlas and the axis,
theyre unique unto themselves, the same with T12, L1. But in the cervical spine,
theyre sort of stretched out like someone blessing a population. In the thoracic
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spine, theyre kind of as though youre holding a stop sign. Theyre up quite high in
the air. And in the lumbar spine, theyre as though youre trying to cut something,
like raise your palm up and point it so your palm is facing to the left. Thats the way
those joints look, like shaking hands straight out. And in each case, their
movements are defined by the position of the facets. Thats very important to know,
and I encourage you to study. We cant into it right here, but its really interesting.
Now here are the poses that work whether its arthritis or a tight muscle, either
case, here are the guys thatll do it.
Ellen Saltonstall: Supta Padangusthasana is a wonderful pose to work with for
any kind of lower back pain thats musculoskeletal because the hamstring is a very
strong muscle that tends to pull the lower back into flexion. It tends to round the
lower back when its tight. So to stretch it with the back safely on a flat position on
the floor, is so good because it really allows a freedom of movement between the
hips and the lumbar spine thats very healthy for daily life, and especially for any
kind of work like lifting things.
So youll notice in both these pictures, theres a blanket under the spine here which
will create that slight bit of anterior tilt in the pelvis, raising the top part of the
pelvis up slightly, and the bottom part of the pelvis where the sitting bones will be
lower on the floor. Thats an anterior tilt of the pelvis which situates the pelvis very
well for stretching the hamstring. The hamstring attaches at the sitting bones and
then goes up to a place above the knee, in this case above because the leg is
vertical. And then youre stretching that entire muscular structure plus the calf
muscle and even into the foot.
On the left-hand side, you see the second leg is bent which will be easier for
beginners. It will help them not to cheat so much. It will help them be more honest
with the pose and get the knee straight of the stretching leg. Then when you can
accomplish it, you want to have the other leg pressing into the floor to stabilize that
tilt of the pelvis, to make sure that the pelvis is properly positioned to maximize the
stretch on the leg that youre working with which in this case is the right leg.
Dr. Loren Fishman: Notice here that the long leg thats elevated, its like a lever.
The hip joint is not situated at the back of the body. The hip joint which is the
fulcrum here, is a couple of inches up from the floor. So when the person pulls on
the foot the way that you see it in both of these pictures, theyre using it as a lever
to stretch the fascia in the lower back, the muscles in the lower back, and moves
those facet joints. Once theyre moved, the pain often goes away just like that.
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Ellen Saltonstall: So this is curative in itself, but its also preventative of the kinds
of danger things that can happen when youre moving around with tight hamstrings
in your life.
Supta Padangusthasana, too, is taking the leg out to the side. We showed two
different slides and we included two slides because the left-hand one has that nice
little sand bag, holding the left thigh down. So thats the leg thats not in the so-
called stretch, but its a very important part of the stretch because it stabilizes the
rest of the body. If you take your leg out to the side without that stabilization, then
youll be torqueing your lumbar spine which could bring on other risks. So the
stabilization of that straight leg thats down will make the pose safer for the lower
back. And then you see on the right-hand side, the person doing the pose without
that sandbag and actually using his own strength to keep the thigh down.
Dr. Loren Fishman: Just what Mr. Iyengar does in Light On Yoga. I would like to
invite you to try this. And once you get into position, the straight leg thats going
straight down, the stabilizing leg, stretch the heel out, and you will feel the different
facets in your back move. This is a wonderful pose for facet syndrome. It doesnt
hurt them, but it moves that exact tissue you want to move, the little facet joints.
Get into position first then stretch your heel like pointing your toe. Dont point your
toe. Point your heel.
Heres one that will obviously help with the facet joint. But is it always as good as
Supta Padangusthasana II? You can see what this does to the facet joint in both
pictures, actually, on the right. You can see there are many versions of this, and
each of them will do it to a different extent. You might want to start with the way it
looks on the right and move to the one on the left.
Ellen Saltonstall: The one on the right, obviously her hand is not down on her
leg, so shes not bending as far to the side. This will be a very safe way to start.
Shes got her foot stabilized against a block, against the chair. Shes got the support
of the chair so that she doesnt go too far. And then she doesnt have her other arm
raised up, so its a milder version. Then on the left, you see a more intense version,
but she still has support of the wall which I think is so important. When youre
dealing with someone in pain, theyll do a much more accurate job of their yoga
poses if they have a little bit of support, especially in the beginning. So shell be
able to bend to the side more clearly and accurately. We all tend to want to go
forward when we bend to the side because it actually makes the movement feel like
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its going further. A little bit of forward bend in these poses is okay, but in order to
get to the side bend, the wall is just so helpful because its a reference point and a
stabilizer.
Dr. Loren Fishman: The other point about using the wall is if you dont, when
balance is an issue, all kinds of extra muscles come into play. The abdominal
muscles get tight. The muscles of the arms start to regulate how your torso is
moving. And the tighter the muscles get, the less motion youll get. The less motion
you get, the less chance of moving that facet thats in trouble. So support is good
here.
Ellen Saltonstall: Now we have two beautiful twisting poses, both of which are
quite challenging. But you can work towards them step by step. The pose on the
left, Pavrita Janu Shirshasana, pose on the right is Pavitra Ardha Chandrasana. So
the pose on the right is a deeper side bend, obviously, because youre bending over
your extended leg. So this one you can approach very gradually, by first going a
little bit forward and twisting the spine. Obviously many people will not be able to
reach both their hands to touch the foot like this beautiful demonstration does. But
in any case, it can be a very effective side bending pose. Then the twisted Ardha
Chandrasana obviously will move the facets in a good way. This is not an extreme
side bend or even forward bend, so its a really good way to get the spinal
segments to move.
Dr. Loren Fishman: I look at this one more as preventative, both of them. Theyre
pretty hard when youre in the position, but if you dont want to get this happening
and you love these poses, its a good way to prevent facet syndrome or segmental
stability.
Now lets talk about another kind of back pain, musculoskeletal in its origins. Its a
completely different flavor. It first get the name from people getting a Harrington
Rod for scoliosis and thats not very common. But the back gets too flat. If you
recall if youve been in a museum and seen an old Henry Ford shock absorber, its a
curved piece of steel. And because its curved, it bends further when the car goes
over a bump. Its a long curve that goes from the front wheels to the back wheels.
Well, thats the way the spine works, too. If it has no curve, then it has no ability to
to absorb any kind of sideward pressure. Up and down pressure is zero. So the
point of this is that when the back is curved a little, it is a much more versatile
instrument.
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The pain that you get in this kind of syndrome is partially due to that, that you have
very little flexibility. But its also due to the fact that when you do have flexibility,
the muscles get tight. And the tighter it gets, the more it hurts. And the more it
hurts, the tighter it gets. Its a closed box. Its a terrible position to be in, and you
see the people in it almost every day.
The muscles that are involved, Ill show you on the next slide, its really pretty
gruesome. Its everywhere. That lumbosacral fascia is being pulled. Its tough. Its
richly invested with nerves. It cant move and it cant stay still that way for very
long because it hurts too much. All kinds of muscle, the semispinalis, the capitis and
not capitis muscles, the serratus posterior inferior where the upward diagonal
arrows are, the transversalis or transversus abdominus where the horizontal arrows
are, and the gluteus maximus where the diagonals are all pulling on that same
sensitive structure, not good.
So what do you do? Theres plenty of things to do. Weve already talked about Janu
Shirshasana and Pavrita Janu Shirshasana which will take the lumbar fascia one side
at a time. Very often, you need to use poses that will prepare you for those two, for
the twist of Ardha Matsyendrasana and Pavrita Trikonasana. Lets go through a few
of them.
Ellen Saltonstall: Here are two modified versions of Janu Shirshasana that are
excellent, really excellent for stretching the lower back. Using the chair allows
people to go into a higher version which will still give a good stretch without
straining too far down into the lumbar vertebra. We show it here with the chair,
head resting on the chair, arms reaching up the back of the chair, and then with the
belt. These are two classic ways to practice Janu Shirshasana.
Dr. Loren Fishman: Notice the back stays straight. I mean, if you have
osteoporosis, you can still do these poses. Youre stretching the back just enough.
This is the misnamed Janu Shirshasana. Misnamed because you dont really bring
your head to your knee. You really bring your belly button to your thigh. You come
forward, not down. Then the Pavrita Janu Shirshasana you can see on the right also
the head is not at the knee. Nevertheless, its an excellent pose for the flat back,
because it takes the lumbar fascia one side at a time, the old Roman strategy
divide and conquer.
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Ellen Saltonstall: We have two moderate poses, one weve already looked at, the
one on the right, Malasana, which is very, very good for stretching the lumbosacral
muscles and the gluteal muscles all of which contribute to flat back. I have many
clients where this is just such an effective pose. Then the twist on the left, this also
is a really good pose for the facet syndrome people, too, because youre moving the
different segments of the spine such that all the muscles involved will be stretched
the transversalis and all the muscles that go up the spine. Everything is loosened
by this very simple twisting pose. And people can do it with their clothes on. They
can do it in their office, at their desk.
Dr. Loren Fishman: Its really a nice way to do it. Then we have Ardha
Matsyendrasana and Pavrita Trikonasana, both of which obviously will stretch the
lumbar fascia. I hope its pretty obvious. Theyre more advanced. You couldnt start
here with people but you get here. I find when I treat people that have this with
yoga, it often takes me up to an hour to get them better. You just have to get them
lose enough and they have to get confidence in you. And they have to get the
opposite, too. You have to be able to show your humility. And the way you do it in
my opinion is to say, Is this better? Do you have any effect with this? Keep
communication with them. Otherwise, they go right back to spinning into the orbit
that made them in pain in the first place.
Ellen Saltonstall: In both of these, you can see clearly that the spine is elongated
and the head is in line with the pelvis. So its really important with twists. And this
is, of course, true for osteoporosis, as well, to keep the spine long and to keep
shoulders level and to keep the head in line with the pelvis. Because otherwise, you
might be causing more trouble while youre getting more mobility into the spine. So
both of these twists are very basic and can be modified. You can see on the left, the
person is sitting up on a blanket. You can even sit up higher, you can sit up on a
block or even a chair to practice this pose which will make it easier for a beginner.
In the pose on the right, Pavrita Trikonasana, shes got a block, but you could even
use two blocks. You can make the pose much milder at first to have the student
understand really what the twist is, how to keep the spine long, how to keep the
head and the pelvis in one long line.
Now we have this more compete version of each pose. She doesnt have extra
props. Shes doing a deeper twist with her elbow to knee on the left-hand slide, and
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0then shes leaning against the wall on the right-hand slide which is a very good
way to practice Pavrita Trikonasana. It gives confidence to people when theyre
doing this difficult pose. This pose requires a lot of stretch of the gluteal muscles
and that can be almost a shock to people if they havent practiced it much, how
much it demands of the legs when its really You know, you think of it, Oh, this is
the spinal twist, but it really demands a lot of the leg.
Dr. Loren Fishman: The way you start the Pavrita Trikonasana is by facing the
wall, and then you twist around like this. Its an excellent way to do it. And again,
the stability of the wall helps a lot. And the wall is a very good teacher its
consistence and confidential.
Eva Norlyk Smith: Loren, I just want to make sure we have enough time for
questions.
Dr. Loren Fishman: Lets stop right here for the night and have questions.
Eva Norlyk Smith: Good, because we got quite a few questions. Shelly from is
saying, Much of the current research in pain science shows that damage or
changes to the spine actually has a poor correlation to low back pain. What do you
think about this and how does that influence the way we address our treatment
approach? So that was, I think what you were addressing about with the muscle
spasms
Dr. Loren Fishman: The first study done like this was done at Harvard by a
woman named Maureen Jensen, and she took a hundred people. All they had to do
to be in her study was never have back pain. She did MRIs on all hundred of them.
Thirty-three of them had whopping pathologies or significant pathologies. This is a
well-known thing. However, you cannot conclude from that all the things you see on
an MRI are worthless. Its a question of clinical judgment and its a tough one. The
more doctors the patient has seen, by the time they see you, the harder its gonna
be and the easier its gonna be. It will be easier because theyve already made a lot
of blunders. It will be harder because this is a difficult case or they wouldnt be
there before you.
Everything youre hearing tonight, you get out that salt shaker, take it with a grain
of salt. Because as I said, five percent of whats supposed to be one way is the
other. Five percent of spinal stenosis responds to extension. Five percent of a
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herniated disc will do better with flexion, for example. All the way through, theres
more here than weve dreamt of in our philosophies or our medicine. There really is.
Its true. Nevertheless, theres something thats wrong and there is a cause. It just
isnt always easy to find it. One more thing to say In many cases in medicine
today, the technology is better than the doctor. Technology gives you an
embarrassment of riches. You can make five diagnoses, probably only one of them
is the main pain generator. Thats the problem that that study turned up and its
something I think well-known to a lot of experienced people.
Eva Norlyk Smith: Lori from Fairfax in California says, When I have an acute
strain, stretching often feels good initially but then hurts when I finish. Should I wait
a while until it settles down?
Dr. Loren Fishman: If it really is a strain, the best thing to do is just to rest it.
Then you will get stiff. And when you get stiff, then you stretch a little bit. The way
the histology works is that when you do a strain, then inflammatory cells rush in not
just to give you grief, they also rush in in order to lay down new collagen fibers and
begin the repair, and heal whatever it is thats not right. And in the course of doing
that, they make it stiff which is a physiological stiffness. Youre stiff because if you
start to stretch it, youll pull out all the work that these good cells are doing. So then
if you wait, I would say ten days, but Id really say three weeks, heres what
happens. After almost immediately, within a day or two, a double strand of collagen
will form in any injury to a connective tissue, like DNA, its a double strand. Its like
first aid. Then three weeks later, almost to the day, the double strand will start to
dissolve and a triple helix will form. Its like braiding a girls hair. And when you get
that, that will be the permanent structure. All the molecules in there will be
exchanged, the structure will remain from then on until you tear it again. So at that
day, twenty-one or so, thats when youre vulnerable again, because the one thing
thats been holding it in, the double helix, is dissolving and the triple helix hasnt yet
formed. So I would say when you have a real sprain, wait a couple weeks. Take it
easy. And then after four weeks or three and a half weeks, then you start to work
very tentatively, very mindfully, until youre back where you started from. No
medicines, no surgery but patience and knowledge of whats going on.
Eva Norlyk Smith: Dan from Oakland is asking, In twisting postures, do you
prefer stabilizing the pelvis or allowing the pelvis to turn in the direction of the
twist?
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Ellen Saltonstall: I much prefer stabilizing the pelvis so that the twist starts in a
minor way in the lumbar spine which doesnt actually have much potential to twist,
and then further up, you twist it even more the further up the spine you go. The
reason I like that better is that I believe that when you twist the pelvis, theres a lot
more chance of error, theres a lot more chance of torqueing the sacroiliac joint and
theres a lot more chance of actually spraining your hip joint. I think twisting with a
stabilized pelvis is better.
Dr. Loren Fishman: I totally agree with Ellen, but I have to add (and she probably
would, too) that if the pelvis moves, its like safety valve. It may mean that youve
gone too far for you at that time. So if it moves a little bit, be patient with yourself.
Understand whats going on and why. Thats really the essence of it. Its surely
better to keep this pelvis stable. Thats the whole point of the pose is to twist. And
when the pelvis moves, you twist less.
Eva Norlyk Smith: Then the last question is for Ellen. Ellen mentioned that chair
malasana is not appropriate for stenosis. Can you please explain why? Thank you.
Ellen Saltonstall: Well, as Loren explained, extension will narrow the spinal canal.
Its really something to test out and see if your pain is helped by it. Its one of those
things where you have to try it. If your pain is helped by forward bending, you start
very gently leaning against the chair and then going down to the floor. I would go
just little by little test it out.
Dr. Loren Fishman: It might really be good for spinal stenosis but its not
something to do with a herniated disc. You shouldnt do flexion like that with a
herniated disc because youre likely to extend and make the disc worse. With a
herniated disc, you do extensions. With a spinal stenosis, you do flexion. But five
percent of the time, its the other way around. This is life.
Eva Norlyk Smith: So we wanted to thank everyone, for joining us tonight. And
we also wanted to extend a special thank you to Loren and Ellen. Obviously, back
pain is a vast subject, and were really pleased, Loren and Ellen, that you joined us
to share your experiences.