Is Savasana Trying to Kill Us? Learning to Recognize & Debunk Fragility Fears

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Savasana is also known as “corpse pose”. But is it really trying to make literal corpses out of us? Well, apparently some people would have us think so!

I’m exaggerating here, of course. No one is actually suggesting that savasana - the relaxing, peaceful pose in which we lie and rest for several minutes at the end of every yoga practice - could potentially kill us. But as difficult as it may be to believe, people are seriously proposing that this classic yoga pose could injure us. And so in the interest of some education on interpreting research papers, a little pain science primer, and a continued encouragement for less fearmongering in the yoga world, I’ve decided to examine this intriguing topic today.

IS SAVASANA OUT TO GET US?

I was prompted to write this piece because of a recent widely-read blog post that was brought to my attention. This blog post cited a research paper that seemed to suggest that savasana could potentially be a harmful pose. In order to support this study’s suggestion, the blog post proposed that because our bodies have adapted to the activity of sitting in chairs, most of us are not well-suited to lying flat on the floor. As a result, when we lie in savasana, our back arches and our spine is “compressed” and “overloaded”. The author writes: “For many, lying on the floor creates much higher loads on weakened tissue than you might expect for something as ‘simple’ as lying on the floor.”

The author proposes that instead of lying flat on the floor, most people should bolster their head and shoulders up higher in savasana in order to re-arrange the position of their body and avoid potential injury in the pose.

Before we examine this claim further, let’s first take a look at the research paper that was cited in order to justify the notion that savasana is injurious.


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THE RESEARCH PAPER ON YOGA & INJURIES: A VERY PROBLEMATIC STUDY

I obtained a copy of the full study in question in order to explore its claims further. Titled “Soft Tissue & Bony Injuries Attributed to the Practice of Yoga” (Lee et al 2019), the researchers retrospectively reviewed the medical records of 89 patients who claimed to have experienced yoga-related injuries. According to the researchers, there were 12 “patient reported yoga poses that led to injury” (page 427), and one of these poses was savasana.

This study is significantly problematic for many reasons. First of all, it is a retrospective study, which is a very low-quality form of evidence that relies only on subjective recollections (i.e. anecdotes and not secondary data) to begin with.

Second of all, this study in no way establishes causation between savasana and injury. At most, the study might show that a handful of people claimed to experience a symptom of pain or discomfort while in savasana. This does not establish injury. Additionally, it does not establish time order between the two variables (a necessity for determining causation), and it does not examine any of the myriad alternate explanations that could be (and most likely are!) involved in the reported pain experienced during savasana.

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Another important point about this study is that it was not done on a representative, random sample of people who do yoga, and is therefore not generalizable to the greater yoga population. The people selected for the study all attended the same medical clinic and they all had significant comorbid health conditions such as osteoporosis, cancer, and hyperlipidemia. Therefore we can’t make any inferences from this study about the general population of yoga practitioners.

Furthermore, the researchers did not include any non-injured patients, which means they selected on the dependent variable only. What about all of the people who went into the clinic who happened to practice yoga and were not injured? These patients weren’t considered in this study. And we can safely assume that they all did savasana at the end of every single one of their yoga classes. Why didn’t this injurious pose send them into the clinic as well?

For these and many other reasons that we don’t have time to discuss here, this study is not causal, is not valid, and is honestly not worthy of citing due to its extremely poor quality design. In fact, in the words of an academic researcher I consulted about this study (who just so happens to be my husband :) ): “From a causal standpoint, this study is garbage.”



FLAWED STUDY ASIDE - WHAT ABOUT PAIN SCIENCE?

We’ve established that the study in question is deeply flawed. But that major problem aside, where is an understanding of modern pain science in either this study or the blog post that cited the study? One of the most foundational insights about pain that we understand today is that the link between pain and tissue damage is quite tenuous. Many people experience pain in their bodies with no associated damage, and many people have damage in their tissues and no associated pain.

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This means that just because something hurts or is uncomfortable does not necessarily mean that tissue damage is taking place. A helpful phrase commonly used in the therapeutic and rehabilitation worlds these days is “hurt does not equal harm”, and I believe this is a crucial insight that is missing from this discussion about savasana and injury.

Additionally, we know that in order to sustain an injury (tissue damage), the forces involved generally need to be significantly high and/or fast. The simple act of lying on the floor in savasana includes neither high nor fast forces. It is simply not plausible that this benign pose could actually cause tissue damage in our body.

Now I definitely don’t disagree with the blog post author that many people feel discomfort while lying flat on the floor in savasana. This is absolutely true, and many of us could find a more comfortable and relaxing pose by adding some props so that our body feels more supported.

But there’s an important difference between suggesting that people should prop their savasana up for comfort and suggesting that they should prop their savasana up in order to avoid injury. The former will help people find more ease and potentially embody more “yoga” in their pose; the latter will potentially serve as a nocebo - a negative expectation of an otherwise harmless event or action that causes negative consequences like pain.

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Suggesting that savasana can harm us is nocebic because we understand today that pain is a multifactorial output of our nervous system that can be influenced by many factors beyond biomechanical ones. Beliefs and social influences are two well-established contributors to painful experiences (among many other psychological and social factors as well.)

The more that we spread a message about the fragility and vulnerability of our tissues (especially in low-load contexts that can not realistically injure us), the more we can influence people to have less confidence and trust in the innate strength and robusticity in their body. This can result in people’s nervous systems creating more painful perceptions than they otherwise would have in innocent yoga poses like savasana and beyond.


IN CONCLUSION…

It’s easy for well-meaning yoga and movement teachers to cause unintentional harm when communicating about the human body. The more we can educate ourselves about pain science and the potential negative effects of nocebos, the more likely we will be to teach about the body in productive, empowering ways.

Additionally, I encourage all of us (including myself!) to become more active consumers of knowledge. If we see a single study being used to make a broad claim, rather than taking that claim at face value, we would be wise to feel skeptical and potentially conduct some of our own research to investigate further.

And finally - setting the science and the flawed study aside, let’s not forget the power of common sense. I mean… savasana? Really? Have we become such feeble creatures that we can’t lie on the floor without harming ourselves? We should feel justified in using our common sense to question such claims.

EXPERT Q&A ON YOGA, STRETCHING & INJURIES W/GREG LEHMAN

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As a member of the yoga community for many years, I regularly hear claims made about how stretching affects the body. These claims vary widely, and I’ve heard everything from “stretching is a magical cure that will heal all of your ailments” to “stretching is damaging for the body, and therefore yoga is bad for us.”

I try to be as evidence-based as possible in my approach to yoga, so I’m naturally skeptical of claims that appear to lack scientific support. In order to clarify some of the truth versus fiction regarding stretching for both myself and the greater yoga community, I decided to consult with an expert who is extremely up-to-date on the most current scientific research on stretching.

Dr. Greg Lehman, BKin, MSc, DC, MScPT, is a Clinical Educator, Physiotherapist, Chiropractor, and Strength and Conditioning Specialist. He travels the world teaching his Reconciling Biomechanics with Pain Science course to health & fitness professionals. He is also the creator of the “Recovery Strategies” pain workbook, which is an amazing, informative, and free resource for anyone in pain. Greg’s work has had a profound impact on the therapeutic, fitness, and yoga/movement worlds, and I am incredibly honored to feature his insight on my blog!

YOGA & STRETCHING Q&A W/GREG LEHMAN

QUESTION 1: In the yoga world, there is a widespread claim that stretching can lengthen connective tissues like ligaments & tendons, causing them to become lax and leading to "joint instability". Is this a biologically plausible assertion?

ANSWER: There is no evidence that this actually happens.  Pretty unbelievable, eh? There is certainly more evidence that suggests when you pull (apply tension) to connective tissue it responds by getting stiffer, stronger and sometimes thicker.  Old research by Dr. Woo has shown this consistently.  The only consistent thing that can make connective tissue less stiff is immobilization and injury.  So, it is possible that people who gain massive amounts of flexibility may have at some point damaged their tissue. 

If people feel “lax” because they stretch I would guess that it would be more of muscle or nervous system change.  People may not have the strength in those ranges to control the motion rather than the idea that they lengthened connective tissue constraints.

 

QUESTION 2: What exactly does "stability" mean when it comes to our joints, and is there evidence to support that a lack of joint stability causes pain and/or dysfunction?

ANSWER: A stable joint system just means when it gets perturbed or jostled it comes back to its resting place.  But, people have expanded the definition to mean that a joint just moves a lot when you don’t want it to move.  Joint instability is a problem when a joint pops out of place and does not readily go back into place.  It certainly does happen but I doubt it’s that common.

 

QUESTION 3: Can passively stretching a muscle compromise its strength (i.e. decrease its ability to produce force)?

ANSWER: Not significantly, meaning 1-5% of max force production [if stretching immediately prior to a strength activity].  And since we regularly don’t need to produce max force it’s not really an issue.  And you only get this transient force reduction when you hold a static stretch for 45 or more seconds.  Some research (Blazevich) even suggests that these max force/power losses are mitigated or completely ameliorated provided you do a warm up.

There is no reason to think that long-term stretching will make you weak.

 

QUESTION 4: Aside from concerns about lengthening ligaments & tendons that we've already covered here, is it inherently injurious or damaging for the body to spend time in passive end range stretches? What about for someone with a connective tissue disorder such as generalized joint hypermobility (GJH) or Ehlers-Danlos Syndrome (EDS)?

ANSWER: I think with EDS it makes sense to limit those movements and get strong instead.  That’s one of those conditions where shit really does pop out of place.  But for other people, who cares if you hang out at end range. You are just applying tensile load to tissue (pretty much what strength training does but at other ROMs) and the tissue will adapt by getting stronger. 

We aren’t made of taffy.  We don’t really “stretch” that way with applied loading like end ROM stretching.  I don’t think it’s injurious but you could certainly argue that there are better options to achieve health and mobility – like adding strength training or even resistance throughout the range of motion.

 

QUESTION 5: There is a growing dialog in the yoga world about the distinction between active & passive stretching, with a new emphasis being placed on the benefits of training active strength & control through our ranges of motion ("active stretching") and a de-emphasis being placed on passive stretching. The reasoning goes that if we have more passive ROM available at a joint than active ROM, we are more susceptible to injury because we lack "control" in those end ranges. Would you agree with this line of thought?

ANSWER: I think you should do both.  I wouldn’t be worried about injury though.  I don’t think most people are getting injured because they have lost “control” of the joint.  Further, if you get injured because the joint suddenly goes to end ROM, it’s not strength at end ROM that would have helped you - it’s the strength and control that you needed before you went to end ROM. 

 

QUESTION 6: Many long-term yoga practitioners have discovered through imaging that they have a hip labral tear, and yoga is often blamed as the cause of this tear. Given that yoga is a low-load activity and that a majority of people in general will develop an asymptomatic labral tear as they age [Ref, Ref, Ref, Ref], is a long-term yoga practice a likely cause of a hip labral tear?

ANSWER: Labral tears are common. Heck, they might even be beneficial for performance.  It’s not unreasonable to think that ANY activity can predispose you to joint changes.  They happen and I doubt there is much we can do about it.  You will see labral tears and bony changes in most sports. 

So should we stop physical activity because of the chance of a labral tear? No. There are way too many benefits from a movement practice that far outweigh the negatives of a potential increase in the chance of having a labral tear.

 

QUESTION 7: In terms of stretching physiology, I believe that many people conflate the "muscle spindle stretch reflex" (reflexive muscular contraction during a stretch) with "stretch tolerance" (tolerating the discomfort of stretching) in their minds. Could you describe the difference between these two phenomena? Do they both play a role in stopping us at the end range of a stretch?

ANSWER: I’m not sure to be honest.  Stretch tolerance definitely plays a role as the stretch is stopped (in the experimental studies) when the participant says its too much.  What happens with long term stretching is that you are able to go farther without there being a dramatic change in tissue qualities.  Meaning we assume that the changes in ROM are due to your tolerance or perhaps habituation rather than a structural change.

The muscle spindle stretch reflex is assumed to not be occurring during end ROM stretching because in these studies they monitor muscle activity.  Meaning, they try to make sure there is no measurable muscle activity that occurs at end ROM.  We assume its just a passive resistance to stretch.  However, it is plausible that there is minor amount of activity that isn’t being picked up and this could be “putting on the brakes”.

 

QUESTION 8: Do you believe there are ways in which passive stretching could actually be beneficial for the body on a musculoskeletal level? If so, how?

ANSWER: Yes.  I think long term stretching is just passive tensile force and tension has the ability to create positive structural adaptations in tissue.  Some (Kubo) have argued that passive stretching can make tendon more efficient.  Others suggest that passive stretching influences muscle stiffness which might be good to balance the stiffness changes in a tendon that can occur with injury.

I certainly don’t view stretching as a negative which I once did.  I think if you argue against stretching you are really not “against” stretching but more pro some other intervention.  So, if you like to stretch and its helpful for you I would encourage you to keep it up. 

THANK YOU AGAIN TO GREG FOR HIS GENEROSITY IN SHARING HIS KNOWLEDGE AND INSIGHT WITH THE YOGA COMMUNITY. I HOPE YOU FOUND THIS INTERVIEW INFORMATIVE AND HELPFUL FOR YOUR YOGA PRACTICE & TEACHING! -JENNI

Learn much more from Greg Lehman on his website here, and follow him on Twitter!


Should Yogis Worry About hips & knees that click & pop?

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When you lower down into squat pose (malasana) in yoga, do your knees make a popping sound? When you lift your leg toward your chest, does your hip sometimes make a clicking or “snapping” noise? What do joint sounds like this mean? Are they dangerous?

As of late, many yoga teachers seem to have taken a fearful turn with regard to joint noises. We often hear the claim that sounds emanating from joints are an indication of a significant dysfunction in the body such as weakness, instability, or tightness. We are cautioned that we should take immediate action to remedy these dysfunctions, or else we will face negative consequences such as joint degeneration and eventual joint replacement surgery in the future.

Now we all want our joints to stay healthy and move well for us as long as possible. This is a major focus of the yoga and movement classes that I offer, so I’m always interested in any information about the body that can help me guide my students toward increased joint health and longevity.

However, it turns out that the scientific literature on joint noise such as knee popping and hip snapping is clear. If you experience a joint noise that is accompanied by pain, swelling, or an acute injury, you should see a medical professional to have the joint evaluated. However, if your joint noise is pain-free and asymptomatic (which the vast majority of bodily joint noises are), there is no reason for concern.

A very helpful graphic by Matthew Dancigers, Doctor of Physical Therapy, that I saw on  his Instagram feed .

A very helpful graphic by Matthew Dancigers, Doctor of Physical Therapy, that I saw on his Instagram feed.

DEMYSTIFYING JOINT NOISES

Joint noises are actually a normal, natural by-product of movement. The catch-all medical term for all of the interesting sounds that joints can emanate is crepitus. Examples of joint crepitus include clicking, popping, snapping, clunking, and more. The exact mechanism for the noise we hear when a joint clicks or pops is still not known, but some common explanations include anatomical structures coming into contact with each other, and the formation or collapse of air bubbles within joint cavities [Ref], [Ref].

Joint crepitus is more prevalent and obvious to hear in some bodies and than in others, but despite the fearful messages that we commonly hear about them in the yoga world, these noises on their own (i.e. unaccompanied by pain, swelling, or injury) are simply a normal physiological phenomenon that are nothing to be concerned about.

 

A CLOSER LOOK AT KNEES

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It’s common for people’s knees to click and pop when they flex and extend them - thus those knee pops we often hear when students lower into their squat (malasana) poses in yoga class. Many people believe that these noises are a sign that their knee joints are “wearing away”, that their bodies are prematurely aging, or that they have arthritis. But did you know that in a cohort of 250 subjects with normal, pain-free knees, 99% of them had knees that made noise? [Ref]. This is how prevalent, normal, and benign knee noises are. Yes, some arthritic knees can have joint crepitus - but so do most healthy knees. No definitive link between joint noise and joint pathology has been demonstrated by research [Ref].

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In fact, in this same study I mentioned above, the remarkable suggestion is made that knees that make noise are actually healthier than knees that do not. I’ll give you a moment to pause and absorb this thought, because it is the complete opposite of the cautions we usually hear. Knees that make noise might be healthier than knees that don’t. It’s true!

Without going too far into the details, the basic idea is that there is one type of knee sound that specifically happens in joints that are mobile and well-lubricated. As a knee becomes arthritic and starts to lose mobility, this type of crepitus actually decreases. So when this sound is absent, it can be a sign of an unhealthy joint with arthritis and decreased joint lubrication - not the other way around!

Therefore despite popular thought, noisy knees are normal and very common. And rather than being associated with joint degeneration and dysfunction, research suggests that knee crepitus is actually associated with healthy knees!

 

A CLOSER LOOK AT THE HIPS

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Hips that click, pop, and snap when they move are another joint noise we are often taught to worry about in the yoga world. This noise is commonly the result of either the psoas tendon moving across a bony prominence on the front of the pelvis, or the iliotibial band moving over the greater trochanter of the femur.

Although this type of hip noise is often claimed by yoga teachers to mean that one has a dysfunctional, unstable, or problematic hip that should be addressed, the scientific literature actually points to the same conclusion I mentioned in the beginning of this piece: if a snapping, popping, hip is accompanied by pain, seeing a medical professional is certainly advised. (The issue is generally resolved through conservative treatment, which is great!) But if the hip noise is pain-free and asymptomatic (as most hip noises are), there is nothing to be concerned about. Here are a few quotes I pulled from the scientific literature on this topic:

“When pain is not present [with snapping hip], treatment is not warranted” [Snapping Hip Syndrome (Musick 2017)].

“[Snapping hip is] a common asymptomatic condition which may occur in up to 10% of the general population” [Endoscopic Release of Internal Snapping Hip: A Literature Review (Via et al 2016)].

And my personal favorite: “Snapping caused by the iliopsoas tendon… is a common incidental observation that often requires little treatment on the part of the clinician other than assurance to the patient that this finding is not a harbinger of future problems” [Evaluation and Management of the Snapping Iliopsoas Tendon (Byrd 2006)].

This serves as further evidence that audible joint noises are normal, and are not a necessarily a sign of dysfunction in the body.

 

THE MOST CLASSIC EXAMPLE: KNUCKLE CRACKING

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Perhaps knee and hip noises don’t warrant concern if they are pain-free, but what about the sounds associated with knuckle cracking? We are probably all familiar with the caution that cracking your knuckles will give you arthritis later on in life. But it turns out that this warning is unsubstantiated as well.

We knew this as far back as 1975, when a study conducted found no correlation between knuckle-cracking and arthritis. A quote from this paper reads: “The data fail to support evidence that knuckle cracking leads to degenerative changes in the metacarpal phalangeal joints in old age. The chief morbid consequence of knuckle cracking would appear to be its annoying effect on the observer.” [Ref]

Additionally, a more recent study on knuckle cracking from 1990 looked at 300 subjects and compared those who did and did not habitually crack their knuckles. It found that “there was no increased preponderance of arthritis of the hand in either group” [Ref].

 

WORRY AND FEAR-AVOIDANCE OF BENIGN BODY NOISES

As we can see, the evidence about joint noises is clear: if they’re accompanied by pain, swelling, or injury, you should see a medical professional for an evaluation. But if they are asymptomatic and pain-free, there is no need to worry about them.

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In reality, the human body is not a perfectly silent organism. Our insides naturally make noises due to normal physiological processes. Think about the sounds we sometimes hear when we are digesting our food, or the sound of our heartbeat when we’re exercising. Joint noises are simply another form of sound that can be a by-product of movement.

Rather than encouraging worry and catastrophizing, we should see asymptomatic joint noises as a normal part of healthy movement. When we teach people that certain movements and joint sounds are inherently worrisome, this can encourage fear-avoidance behavior and a reduction in movement, which have their own negative consequences and can ironically contribute to pain.

As physiotherapist Clare Robertson writes in her excellent paper titled Joint Crepitus - Are We Failing Our Patients?:

“To accurately inform and reduce anxiety is likely to empower patients and reduce their risk of catastrophizing... It is well documented that there is a clear link between catastrophizing and long-term poor outcome within musculoskeletal medicine.” [Ref]

 

P.S. If you find the topic of joint crepitus interesting, you might enjoy this short video from Physiotutors, a source for evidence-based physiotherapy education:

 

5 Things We Didn't Learn About the SI Joint in Yoga Teacher Training

Today I'd like to offer 5 insights about the SI joint (or sacroiliac joint) that we don't tend to learn about in yoga teacher training, but which definitely have implications for how we teach and practice yoga. Also included are multiple scientific references for each point. I invite you to read these points with an open mind and a willingness to possibly question your own biases (because I know I have had to question my own many times as I continue to study and learn about the body!)

 

 

Insight #1: The SI joint is a strong, resilient structure that is supported by thick layers of some of the strongest ligaments and muscles in the body. [Ref, Ref, Ref]


Although the SI joints are some of the strongest joints in the body, we often receive the impression from our yoga teacher trainings that they are actually quite fragile structures that are vulnerable to injury and instability from the slightest misalignments in yoga. For example, we are sometimes taught that if we hold our pelvis "square" when we twist in poses like twisting triangle (parivrtta trikonasana), we can "tweak" our SI joints by pulling them out of alignment, and we should therefore instead always be mindful to let our pelvis turn slightly in the direction we are twisting in these poses. Another example is that we are often instructed in backbends like bridge pose (setu bandha sarvangasana) and locust pose (shalabhasana) to relax our glutes (or to at least soften them somewhat) because if we contract them too hard, this could injure our SI joints.

One reason we tend to believe that our SI joints are vulnerable to damage in yoga is that we generally learn about SI joint anatomy by looking at a skeleton model or a drawing like this one here:

 
 

When we see the bones by themselves like this, we can certainly get the impression that the sacrum can "slide around" relative to the pelvis easily, resulting in an SI joint that can be pulled "out of place" or "strained" due to small misalignments in yoga poses.

However, what we rarely see after learning about the bony anatomy of the SI joint's structure is an image like this, which depicts all of the extremely resilient, tough ligaments that surround and support the SI joints from all sides, holding them firmly in place:

The ligaments that support the SI joint include the anterior sacroiliac ligament, interosseus sacroiliac ligament, sacrotuberous ligament, posterior sacroiliac ligament, and sacrospinous ligament.

The ligaments that support the SI joint include the anterior sacroiliac ligament, interosseus sacroiliac ligament, sacrotuberous ligament, posterior sacroiliac ligament, and sacrospinous ligament.

 

A rarely-cited fact is that the ligaments of the SI joint include some of the strongest ligaments in the human body! [Ref]

If after seeing an image of the SI joint's ligamentous support, we were then shown an image like this one below, which depicts all of the thick musculature and fascia on top of all of those ligaments on top of the SI joints (including the powerful gluteus maximus, the largest muscle in the human body), we might have reason to be more confident and less fearful about this naturally strong, sturdy area of our body:

 
 

 

While our SI joint can certainly be injured and we can absolutely experience pain there (more on this in #4), it would take much more force to injure a healthy SI joint than the relatively low loads involved in a yoga practice.

 

Insight # 2: The SI joints are inherently stable by design, not inherently vulnerable. [RefRef, Ref]

The SI joints serve to transfer the load of the upper body to the lower body, as well as to distribute forces moving up the body from below. Therefore, stability is built into their very design so that these forces can be transferred efficiently through the pelvis.

In fact, the SI joints are so inherently stable that there is only the tiniest amount of movement available at these joints. While some sources state that the amount of motion available at the SI joint is a barely-perceptible 2-4 millimeters, other sources actually state that there is in fact no movement available at these joints at all.

 

Insight #3: Even if the SI joints could "slip out of place" easily, we don't have a reliable way to assess this in someone's body. [Ref, RefRef, Ref, Ref]

SI joint movement is so minute and difficult to identify with either manual palpation or radiographic imaging that none of the tests traditionally done to assess the SI joint have been shown to be reliable. Without an accurate method for testing the position and movement of an SI joint, how can we definitively know that someone's SI joint is "out of place", "misaligned", or "unstable" in the first place?

 

Insight #4: SI joint pain is certainly a common experience among yogis and non-yogis alike, but SI joint pain does not necessarily mean that there is an SI joint injury. [Ref]

His left hand would actually be a bit lower if this were truly SI joint pain. (I couldn't find a photo that showed the right spot - they all seem to feature general low back pain instead!)

His left hand would actually be a bit lower if this were truly SI joint pain. (I couldn't find a photo that showed the right spot - they all seem to feature general low back pain instead!)

Thankfully, insights from modern pain science are beginning to become more widely known in the yoga world, but if this topic is new to you, consider taking a look at the introduction to pain science article that I wrote for Yoga International a couple of years ago. It turns out that despite what we have traditionally been taught, pain and tissue damage often do not correlate on a 1:1 basis - especially when pain is experienced in a more persistent or chronic way. Pain is actually a much more complex, multi-factorial phenomenon than simply "I have tissue damage and therefore that is what is creating my pain."

As an example, if someone has SI joint pain and they have experienced a recent blunt force trauma to their pelvis region (think from a car accident or a major fall of some sort), then their pain is very likely due to an actual SI joint injury. Once this injury has healed, this pain should subside. In fact, my husband and I suspect that his SI joint may have been injured many years ago in yoga by a strong adjustment he received. His yoga teacher forcefully pulled both of his legs behind his head in a pose called dwipada sirsasana and he felt a searing pain at his left SI joint in that moment. Thankfully the injury healed, but this type of forceful, deep adjustment seems like it was enough to cause injury to his SI joint (or at least a strong protective output of pain in the area).

But in contrast to those examples of short-term pain associated with acute injury, when someone's SI joint pain is more long-term or chronic in nature (chronic pain is sometimes defined as pain lasting longer than 3 months), it's less likely that this pain is connected to a specific injury or damage to the area, and more likely that the person's nervous system is instead sensitive around that spot. Nervous system sensitivity and an output of pain can be the result of many different factors aside from actual tissue damage. Other influences include emotions, past experiences, stress levels, beliefs - and particularly beliefs about one's body. In fact, the more that someone believes that their SI joints are fragile and vulnerable, the more likely their nervous system is to perceive threat in that area and to output pain there. And conversely, the more someone learns that their SI joints are strong, inherently stable structures well-supported by some of the most durable ligaments and muscles of the body, the less likely their nervous system will be to perceive threat and output pain in this area. [Ref, Ref]

 

Insight #5: Warnings about protecting the SI joint in yoga are often unnecessary.

As we have seen, the SI joints are held stable by a ligamentous and musculature support structure that is strong and resilient - and the joints themselves have only a tiny amount of movement available (if any) in the first place. With this in mind, whether or not we hold our pelvis square when we twist in yoga is probably not a likely mechanism for SI joint injury either way, given the relatively low loads involved in the pose. And whether or not we squeeze our glutes in backbends in yoga is also unlikely to be a mechanism for SI joint injury; in fact, contrary to the common cautions in yoga, contracting our glutes in backbends has actually been shown to have a positive stabilizing effect on the SI joints. [Ref, Ref]

Additionally, it's common these days to hear warnings about "overstretching" the ligaments of the SI joints in yoga poses, leading to SI joint instability and pain. (I myself used to offer such cautions too - the idea just seems to make sense!) We are learning, however, that this is not actually how ligaments respond to stretching. During a stretch, a ligament lengthens temporarily, but then it returns to its resting length afterward (sometimes after a short recovery period.) Despite popular warnings, passive stretching has not been shown to lengthen and destabilize ligaments and joints. I have personally changed my perspective on this issue due to insights from newer research and teachings from my yoga biomechanics mentor Jules Mitchell.

(For more reading on the fascinating topic of stretching, ligaments, and joint instability with lots of research references cited, I encourage you to read this recent blog post by Greg Lehman, a researcher and clinician whose work I have followed and admired for quite some time now. But fair warning: this post is long and is really territory for the more serious body geeks among us. You can always jump right to "Questionable Assertion #3", which specifically addresses these topics and might offer some new, interesting information for you to ponder.)

 

IN CONCLUSION...

In summary, SI joint pain is common among yogis and non-yogis alike and there are many factors that can contribute to it, including physical, psychological, and social ones. How we align our body in yoga is probably not a mechanism for SI joint injury, though (strong, forceful adjustments by yoga teachers excepted!) Rather than worrying too much about alignment for SI joint protection, a more effective means to injury-prevention is to simply strengthen and condition the muscles and connective tissue that support the SI joint, so that their capacity to handle load increases.

Thank you for reading these 5 points with an open mind, and I hope to see you on the mat virtually or in person in the near future!

**Related: Keeping Your Yoga Teaching Current Online Training

Podcast Interview: Pain Science For Yoga/Movement Teachers

I was lucky enough to get to talk about pain science and what implications it has for us yoga/pilates/movement teachers on the wonderful Moving Well podcast! Nikki Naab-Levy and Janet Sunderland are the very smart and engaging hosts of this podcast, and I really enjoyed having the opportunity to talk with them about one of my favorite topics to geek out about. :)

I hope you enjoy the interview if you have the chance to listen to it!

4 Basic Pain Science Concepts For Yoga Teachers, Part 1

I recently created a series of social media posts designed to help yoga teachers become better-informed about the complex topic of pain science. Pain science is growing in its reach in the therapeutic, fitness, and movement world, and even though yoga teachers generally don't treat people for pain (unless you're also a physical therapist or other health care professional in addition to being a yoga teacher), pain science actually has many important implications for us beyond the subject of pain itself. As yoga teachers, if we take the time to learn about even a handful of some of pain science's most fundamental insights, we'll be rewarded with a more current and accurate paradigm for approaching and dialoguing about not only pain, but movement, yoga, and bodies in general.

Here is a re-cap of the series of four posts that I shared through my social media channels so that they can be read all in one place together, and I'll follow up with Part 2 of this blog post series with some additional, new thoughts on how and why all of this might matter specifically to us as yoga teachers. I hope you enjoy perusing this info - feel free to share with your networks if you feel that it would be beneficial!


PAIN SCIENCE FACT #1: Pain and tissue damage do not always correlate. In fact, when it comes to persistent pain (often defined as pain lasting more than 3 months), the link between pain and tissue damage is often significantly weaker. (And yes, if you experience a pain that "comes and goes" versus a constant, steady pain that is always there, that is still considered persistent pain if it's been going on for longer than 3 months.)

Reason this is important: just because someone experiences pain somewhere in their body, this does not necessarily mean that there is *actual injured tissue* inside of their body. It might mean that, but it also really might not. (Remember, this is more likely the case when we're talking about persistent pain - not so much with acute pain. Acute pain is the direct result of a recent injury - like stubbing your toe on the door jam or spraining your ankle due to an accidental fall. Acute pain usually lessens and then stops once the injury has healed. Persistent pain, on the other hand, is also often also called chronic pain and is pain that lasts for a longer amount of time.)


PAIN SCIENCE FACT #2: Pain is an output of the brain. This is an often-cited pain science insight - but what does it actually mean? Remember that pain science involves a major perspective shift in how we see the body, so we really have to wrap our minds around some new concepts here. Typically, when we experience pain, we tend to think of the pain as being located "in our tissues", and our brain then senses it there and THEN we feel it. In this view, pain is an INPUT to the brain because it first exists "out there" in the periphery of our body, and then we sense it centrally (in our brain).

As intuitive as this "input" idea seems, it's actually the opposite of how pain really works! In reality, there is no pain *anywhere* in our tissues that is inputted to our brain. Instead, pain is a creation OF the brain that is meant to signal us to take protective action against a perceived threat. If you feel pain in your shoulder, for example, it's because your brain is *outputting* a warning signal to you about that area for some reason. Pain is therefore not an input from your tissues to your brain - it's an output from your brain to your tissues! How mind-trippy is that?

Now your brain might be correct that this painful area is under threat (especially if you recently injured that spot - too many sloppy chaturangas, anyone? Heh heh...) But your brain might also be wrong in its conclusion that the area is under threat - especially if there is no recent tissue damage there. And pain without tissue damage (and vice versa - tissue damage without pain) happens ALL. THE. TIME. Refer back to Pain Science Fact #1 to review this concept, and then see if you can put Fact #1 and #2 together to start to build your new pain science-informed paradigm.


PAIN SCIENCE FACT #3: We've already covered (in a very simplified way) the fact that pain is an output FROM the brain, not an input TO the brain. Pain doesn't exist in one's tissues to be sensed by the brain - it is instead a creation OF the brain to be sensed in one's tissues. But why and when does the brain choose to create pain?

We used to believe that all pain experienced in the body was the result of tissue damage somewhere inside of us - in other words, we thought pain was always the result of some structural problem. But we now understand that tissue damage is just *one input* that the brain considers when deciding whether to emit a pain signal. In addition to tissue damage, the brain considers inputs like past memories, emotions, expectations, beliefs, one's environment, things that health professionals say, and more when deciding whether to output a pain experience in any given moment. All of this information processing happens unconsciously, and in just a fraction of a second.

Now that you know this, think about someone who experiences a persistent pain in their low back (like 80% of us will at some point in our lifetimes). Here is a list of common reasons given when someone has back pain: your spine is out of alignment, you have a herniated disc in your spine, you have poor posture, you flex your lumbar spine too much, your SI joint is dysfunctional, you sit in a chair too much, you have SI joint instability, your core is weak, you have a vertebral subluxation, you lack core stability, your back muscles are tight, etc., etc.

This is a really long list of commonly-cited reasons for back pain, but the interesting thing is that they are ALL structural reasons - meaning that they all have to do with the physical structure of the body. But remember our new Fact #3 from today: the brain takes MANY inputs into consideration before deciding to output pain, and structural inputs are just ONE category of inputs. Combine Fact #3 with Fact #1 (the link between persistent pain and tissue damage is often quite weak), and your paradigm for how you think about someone's back pain might begin to shift and expand.


PAIN SCIENCE FACT #4: We often believe that our body is naturally vulnerable in certain movements or postures, like lumbar flexion, forward head posture ("text neck"), etc. We believe that these positions will injure our tissues and create pain, often blaming someone's low back or neck pain on these "bad postures".

What this viewpoint (that I used to share too!) overlooks is the fact that the tissues of our body are adaptable and become stronger when they are loaded (as long as the load isn't too high). Any movement that you desire to do is a "good" movement as long as your tissues are adapted to withstand its loads. (This is a super oversimplified explanation, but for more info, check out my blog post Are Some Movements Inherently Bad? (which was also re-printed in Yoga International).

Additionally, recall Fact #3 of this series - *many* inputs contribute to pain, not just structural ones. Recent research has strongly suggested that our *beliefs* about pain can directly influence our pain. For example, if we believe that a certain movement is bad for us, this can create what's called a nocebo - the creation or increase of pain or dysfunction based solely on negative expectations and beliefs.

BIG TAKEAWAY: The issue isn't that we need to *avoid* certain "bad" postures and catastrophize them - it's more that we want to move our body in a *wide variety of ways* so that we can be strong and adapted to many different positions. Movement variability is more important than fear of movement!


That concludes the series of posts that I shared through social media, but keep your eyes out for Part 2 of this series, which will attempt to address why all of this matters specifically to us yoga teachers. In the meantime, I also wrote a helpful introduction to pain science in Yoga International earlier this year (see "Yoga & The New Science of Pain"), and at the bottom of that article I included a lengthy list of links for further reading for those interested. Enjoy exploring this topic further if you feel so compelled!

Are Some Movements Inherently Bad?

We are often taught that there are ways the body can move that are inherently bad for us. We’re told that these movements will cause damage, “wear and tear”, or imbalance in the body, which will inevitably lead to pain and discomfort. Some examples of movements like these are cervical spine flexion (e.g. "text neck"), lumbar spine flexion, and many classic yoga alignment taboos like placing the foot directly on the knee in tree pose (vrksasana).

While this perspective is certainly well-meaning, it is missing some key insights about the body that recent science has revealed to us. Instead of asking whether a movement is good or bad, a more nuanced and helpful question is: are one’s tissues adapted to withstand the load of a particular movement? When we approach movement from this perspective, it becomes clear that there are no inherently bad movements - there are simply movements whose loads our bodies are not currently adapted to handle.

 


OUTDATED MODEL OF PAIN

One reason that the "bad movements" belief is unhelpful is that it is based on an outdated model of how pain works. If you read my recent article on The New Science of Pain in Yoga International, you may be familiar with the fact that the link between pain and actual tissue damage is often very weak. Recent studies have repeatedly shown that many people have real tissue damage in their bodies and no associated pain, and conversely, many people who experience chronic pain in their bodies have no associated tissue damage at all. Additionally, pain is not an input to the brain from the periphery of the body (i.e. from tissue damage), but an output from the brain that is meant to signal us to take some sort of protective action.

There are many more implications that the new science of pain has for today’s topic of “bad movements”, but for the sake of time I’m going to to leave this part of the discussion at that and encourage you to read my original article about pain if these ideas are new to you. (This paradigm shift is fascinating and important for us yoga and movement teachers to understand!)

 


DO OUR PARTS WEAR OUT LIKE THE TIRES ON A CAR?

The second main issue with the “bad movement” approach is that it is based on a model that views the body as similar to a car, or a machine. In this model, if we move or align our body in sub-optimal ways over time, certain body parts will wear out before others due to the accumulation of microdamage. Just like a car’s tires might wear out unevenly and need premature replacing if they aren’t aligned properly, our body’s joints (think knees, hips, spinal joints) can wear out if we move or align them poorly.

This idea makes great intuitive sense, but there is an important distinction between cars and human bodies that is missing from this perspective. Unlike a car or a machine, whose parts do mechanically wear out with time, our body consists of living, biological tissues which are constantly turning over and remodeling according to the demands they experience. For example, we all know that if we load our muscles and connective tissues with a weight-training program at the gym, they will respond by becoming stronger in order to handle these loads. Another way of saying this is that the tissues of our body adapt to the stresses placed on them (also known as Davis’ Law).


TEXT-NECK AND TISSUE ADAPTATION

Text-neck is not an inherently damaging movement.

Text-neck is not an inherently damaging movement.

As counterintuitive as it may seem, this same principle of adaptation applies in the case of the traditionally-labelled bad movement of “text-neck”. We are often cautioned that our head weighs the approximate amount of a bowling ball, and for every inch forward that it creeps, our neck is burdened with 10 additional pounds of damaging weight, leading to inevitable pain and imbalance in this area. (I have warned my yoga students about the dangers of text neck myself in the past too - believe me!)

But such cautions are rooted in the model which views our body like a machine full of parts that will wear out and break down if poorly aligned. By contrast, the living, biological organism of our body is constantly adapting to the loads it experiences. Therefore, if you position your head slightly forward of your torso on a regular basis, the muscles, fascia, and connective tissue of your neck will naturally adapt to become stronger and better able to withstand this load.

Now it’s certainly the case that holding any position for a long period of time, be it text-neck or otherwise, is problematic. But simply flexing our neck forward to look down is a natural movement that our body is designed to do. As well-intentioned as the cautions against text-neck are, they are not truly science-based and can encourage unnecessary fear and worry around this movement (which, ironically, can contribute to pain!)

 


“BAD ALIGNMENT” IN TREE POSE

Yoga alignment rules are another realm where "bad movement" beliefs often come into play. One classic example is the instruction that nearly every yoga student has heard to never place the foot on the opposite knee in tree pose (vrksasana). The reasoning behind this alignment rule is that the laterally-oriented force that the foot applies can damage the knee joint. We are instead instructed to always place our foot either above the knee (on the thigh) or below the knee (on the shin).

This alignment taboo does make intuitive sense, but let’s use the lens of biomechanics to look a bit closer. First of all, as we discussed above, the tissues of the body adapt to the loads placed on them. Therefore, in theory, if someone were to practice tree pose with their foot on their knee frequently enough, the tissues of the knee should adapt and get stronger to handle that load.

Secondly, yoga teachers often cue their students to actively press the standing leg and tree leg foot into one another in this pose. If practiced this way, this action actually creates stability in the standing knee joint which should resist any pressure applied by the tree leg foot.

And lastly, tree pose can be practiced with the tree leg actively working to hold itself up, rather than passively leaning against the standing leg. (Picture the leg lifting itself, rotating, and placing the foot on the opposite leg all on its own, without the help of your hand, and then holding itself up there.) In this scenario, the tree leg’s foot would actually be placing no pressure on the standing knee at all.

Upon closer examination, it becomes clear that the classic teaching that foot-on-knee placement in tree pose is inherently “bad alignment” is a questionable belief that probably does not apply to most bodies in this pose.

 


HEADSTAND (SIRSANA)

Another controversial asana in the yoga community is headstand (sirsana), a movement that many wonderful and well-meaning yoga teachers believe should never be practiced because our cervical spine is simply not designed to carry the full weight of our body in such a fashion.

It is absolutely the case that most Western bodies are not adapted to handle the loads that headstand places on their cervical spine. (This is why teaching full headstand to a group class is definitely not advisable!)

But if we look at headstand as a movement that applies certain loads to the body, and if we understand that the tissues of our body adapt to the loads they experience, we begin to realize that if someone were to intelligently and progressively load their cervical spine over time (and it would need to be slowly and over a lot of time!), it would be possible for their body to adapt to the loads of headstand. Sirsana would be a safe asana for this body to practice. It's therefore an oversimplification to state that headstand is an inherently bad movement. It would be more accurate to say that it is simply a movement which many bodies are not currently adapted to handle (but they could be trained with time!)

 

CONCLUSION

When we start thinking about movement in terms of load instead of inherently “good” or “bad”, we gain a more nuanced perspective on the body. It’s true that any movement with high enough loads can injure us, but low load positions that we frequent regularly are unlikely to be the source of damage and pain in our body because our tissues will respond by adapting to handle them. These realizations lead us away from viewing our body as an innately fragile structure that is vulnerable to damage from suboptimal forces, and instead as the strong, resilient, and adaptable organism that it truly is.

Yoga and the New Science of Pain

I'm so excited about my newest article in Yoga International that was just published today! The topic of my piece, Yoga and the New Science of Pain, has been an absolute game-changer for me over the past year-and-a-half or so in terms of how I think about the body, movement, pain, and of course, our amazing yoga practice. I'm honored to have the chance to help spread the word to our yoga community about how pain really works and why this realization is so meaningful for how we see and approach the body in general.

If you're not yet hip to the new paradigm of how pain works and why, this article is a great introduction to the foundational concepts of this exciting new perspective. And if you're already familiar with the new science of pain, it's always helpful to see someone else articulate in their own words this paradigm shift that you know so well.

I am extremely grateful to the many pioneers and early teachers of the new science of pain, several of whom I cited at the bottom of my article. They are major heroes of mine!

I hope you enjoy my introduction to this important, perspective-shifting topic. Don't hesitate to let me know if you have any questions or comments after reading my piece!