At 75, my dad is starting his yoga practice. The facts are as follows; he is basically thin and fit, a tennis player, gardener and avid ballroom dancer. A psychiatrist, which makes him precise, direct and punctuated with shoulder tension. He has a history of asthma and abandonment issues (mother) and above all stays far away from negative emotions. He calls his current girlfriend love muffin, sexy bunny and lover -respectively horrifying and amusing my children. Over Christmas, my sister Johanna wryly stated that it was cute to find dad a yoga class, but we knew he would never go.
Cervical Stenosis: Is when the spinal canal is too small for the spinal cord. A normal canal diameter is approximately 13-15mm and a narrowing of the canal of less than 10mm diameter is associated with cervical stenosis. A canal of below 13mm is considered at risk for stenosis. Symptoms of cervical stenosis include neck pain and numbness, pain in one or both arms, and an electrical sensation that radiates downwards when the head moves. Radiculopathy are pinched nerves as they exit the spinal canal.
Management of spinal stenosis is aimed toward symptom relief and prevention of neurologic complications. Physical therapy with traction and strengthening exercises help relieve symptoms, muscular spasms and back pain. Decompression and inversion tables have also been used with success and varying amounts of benefit. Epidural steroids are also used to treat stenosis. Surgical interventions may be required in some cases.
Cervical stenosis can progress to myelopathy in one third of affected individuals. Myelopathy is defined as pathology of the spinal cord and spondylosis refers to the degenerative changes that occur in the spine.
Cervical Spondylosis Myelopathy (CSM) refers to the clinical presentation from these degenerative processes and is a common degenerative condition of the cervical spine. Degenerative changes of the cervical spine include degeneration of the joints, intervertebral discs, ligaments and connective tissue of the cervical vertebrae and symptoms can include neck and shoulder pain, suboccipital pain and headache, radicular (radiating nerve pain) symptoms. CSM is the most common cause of spinal cord dysfunction in adults older than 55 years has been observed in as many as 95% of asymptomatic individuals older than 65 years.
Dr Loren Fishman, a back-pain and rehabilitative medicine specialist who has long incorporated yoga into patient care and studies Iyengar Yoga, published an article in the New York Times on 5/8/13 called Advice on Practicing Yoga in Middle age.
Responding to questions about practicing yoga with herniated disc Dr. Fishman made the following statements:
– A herniated disc responds to extension, and may be worsened by flexion
– DGR, with bulging discs, is inhibited from back bends by a yoga-phobic physician. But back bends will very likely help.
– And about 5 percent of the time, the treatments reverse: extension helps stenosis, flexion is good for herniated discs.
– Unfortunately, Cate in NY, who also has sciatica and a herniated disk, cannot do either forward or backward bends. But she can do sideways poses like vasisthasana (side plank), which we have shown with M.R.I.s to reduce stenosis and herniated discs.
So I looked in my anatomy books to understand this more specifically:
Intervertebral Discs and Vertebrae: IV discs join the vertebra together. The fluid, gelatinous inner part of the disc is the nucleus pulposus, and is confined by a fibrous ring called the anulus fibrosus. The discs account for 20-25% of the length of the spinal column and at birth the central core of the disc is 88% water. In middle and older age there is a decrease in vertebral bone density, which causes the superior and inferior surface (top and bottom) of the vertebrae to become increasingly concave. Due to this concavity, the IV disc bodies actually increase in size; women 10% and men 2% (front to back) and in thickness about 10% in both genders. Interestingly, this bone loss and thinning of the vertebral mass are believed to account for the majority of age related height loss. The IV discs become circumferentially broader when the spine is compressed and thinner when stretched (as in hanging or suspended).
Herniation: As we age (20-70), the disc dehydrates and the inner and outer part merge together, forcing the outer ring to take more weight with compressive forces. Flexion of the vertebral column creates pressure anteriorly and over stretches the posterior spine squeezing the nucleus pulposus backwards (posterolateral) towards the thin and overstretched anulus fibrosus. Herniation occurs when the nucleus pulposus pushes in to the anulus fibrosus, which in turn pushes on the nerve roots. Posterolateral herniations are the most common and typically the cause of nerve pain due to the proximity of the nerve root. Approximately 95% of posterolateral lumbar herniations are at the L4-L5 or L5-S1 vertebral level.
Sciatica: Is often caused by a herniated L4 disc which compresses the L5 or S1 sciatic nerve root. Chronic sciatica causes pain, which can shoot down the posterior leg, and acute sciatica can be the result of localized nerve inflammation. Other causes include a tight piriformis muscle and spinal stenosis. Hip flexion with knee extension can exacerbate or relieve sciatica. Stretching the piriformis/rotator muscles can relieve sciatic as well.
Spinal Stenosis: The canal (foramina) of the spinal cord can narrow with age and compress the nerve roots as they leave the spine. Lumbar Stenosis is most common in the L4 vertebrae. If there is herniation of L4 along with stenosis it further compromises the already limited vertebral canal.
Moore and Dalley (2006) Clinically Oriented Anatomy, 5th edition, Lippincott Williams & Wilkins, Baltimore, MD.
Lasater, Judith (2009). Yogabody: Anatomy, Kinesiology, and Asana. Rodmell Press, Berkeley, CA.
My 74 year-old father was in town for Memorial Day weekend and I made him take a yoga class. Though fit from years of tennis, gardening, and ballroom dancing, his basic stance on yoga is not atypical of his generation; one of dismissal and moderate disdain. He had his head in his laptop until 2 minutes before we had to leave and then asked me if it was ok to take yoga in jeans. To dad’s credit, he pulled it together nicely and ended up fashion forward in a Patagonia top and a pair of ladies size small sweats from Target.
In class, as the teacher, I saw his competition win over his attitude. He diligently tried to stand up straight, open his chest, position his shoulder girdle and head, straighten his arms and breathe. In supine, he grunted with his neighbor Mike as he attempted to lengthen the back of his legs, open his pelvis and twist his spine. The comments (“I feel like I am in Auschwitz”) began to ebb as he became more internally focused and physically oriented. When seated in a chair for a twist, I saw his tight asthmatic back ribcage begin to open and his energy significantly change.
As the class went into supported shoulder stand, dad insisted he try it. I pretty much assumed he wouldn’t be able to do it, but thought we could give it a go, as I know his health history. I was amazed; he got in it, complained very little, and stayed in it for over 5 minutes! The initial twinge of the chair in his back receded, and afterwards he sunk into a self proclaimed deep and very peaceful final relaxation (he confessed later because he was afraid I was going to make him stand up again, he capitalized on the moment).
When asked by the other class members how he felt after class, dad stated (faint praise is his style) that he “felt better” and “could understand how this could help your body and be good for you” and “would consider doing yoga again if it were available” (he lives in Fargo). Mike, a solid weekly yoga practitioner of over 3 years called him out and made him name his experience.
“Come on Dennis, admit it, you don’t just feel better, you feel good, you feel GOOD” – and the man of faint praise concurred. Total success all around.
You feel better. You age better. You look better. You might live longer. Your metabolism and digestion improve. Your heart and your lungs work harder which increases your lung capacity, and O2 exchange so your brain works better. Your bone density will improve which means you will stand up straighter for longer and may get fewer fractures as you age.
Your appetite will become suppressed so you eat better and hydrate more. Staying fit may lower your odds of heart disease, diabetes type 2 and risk of stroke along with certain types of cancers (women who exercised 10-19 hours a week had a 30% lower risk of breast cancer than that of inactive women; Harvard Women’s Health Watch, Vol. 20, #1).
You will reduce stress. Your muscles will get stronger which will improve your alignment and better support your joints. You will have more energy. Your sleep may be improved. Your mood will improve. You will feel better about yourself. Depression may lift. You will set a good example for your loved ones. You may have fun. You will fit into your old clothes again. You will get out and join life.
Biomechanics of the Weight-Bearing Shoulder after SCI: Implications for Clinical PracticeSara Mulroy, PhD. PT
STOMPS Strength Optimal Movements for Persons with Shoulder Pain
Looked at Shoulder Pain With 15 Items
Predictors of Shoulder Pain Include
4 Recommended Exercises Came Out of This Clinical Trial
Perform in This Order and This Amount!
One of the nice things about my job is that I learn new things. In late June, I was able to attend the 35th Annual Interdisciplinary Spinal Cord Course at the renowned Rehabilitation Institute of Chicago. It was just my second time in Chicago (the first over a decade ago for my cousins wedding), but both the city and the course turned out to be fantastic.
The course spanned three days and consisted of 12 hour long lectures related to evidence based treatment (best practice) of SCI and 3 afternoon lab sessions which focused on more experiential learning. The topics of the lectures I enjoyed the most were the Biomechanics of the Weight-Bearing Shoulder after Spinal Cord Injury: Implications for Clinical Practice by Sara Mulroy, PhD, PT. which emphasized strengthening the rotator cuff muscles to decrease shoulder pain from overuse due to chronic wheel-chair mobility.
The four exercises she recommends are performed with either dynabands or free weights: external rotation (infraspinatus) with the elbow at 90 degrees (8x), shoulder retraction with elbow 90 degrees (15x), thumb up lateral arm raises to shoulder height (supraspinatus, 15x with weights under 7#’s) and diagonal pull downs with straight arms (8x). All exercises can be performed w/c level or standing.
Another course called “Exposing the Skeletons in the closet of SCI Rehab” by W. Brent Edwards, PH.D, emphasized the importance of building bone density to prevent fractures in SCI due to rapid bone density loss: after 2 years 25% in hip and 50% in knees. An alarming 40% of SCI pt’s experience fractures in their lifetime the most common causes being transfers and falls from W/C’s or rolling over in bed. The two methods of reducing bone loss are with acute rehabilitation and pharmacology. Rehabilitation activities include weight-bearing exercises, Functional Electrical Stimulation (FES) and Vibration Stimulation.
Another of my favorite speakers, Jeri Morris, PhD, is a psychologist who emphasized the importance of teamwork to develop a relationship of trust with the patient in Facilitating Adjustment to Spinal Cord Injury: The Power of the Team. She believes that therapists must operate from a “position of benevolence” and understand (and deal with) why patients can be difficult and angry and above all learn to provide reality without taking away hope.
Lastly, I snuck half way through, into a lecture/lab given by Annie O’Connor, PT, OCS, Certified MDT called A Collaborative Approach to Seating: Importance of a Mechanical Therapy Approach. Basically, she specialized is pain (she says she loves it), and gets individuals whom are WC bound and in chronic, intractable, at the end of their rope pain, out of pain through careful analysis, evaluation, treatment and WC modification. It was thrilling to watch her work, a Dr. House of pain.
When I was in Cambodia, one of our group members, Craig, tore his rotator cuff badly and ended up in agonizing pain. He became an overnight patient in a Cambodian hospital not once, but twice. Lets explore the job of the rotator cuff.
The four rotator cuff muscles secure the humeral head into the shallow glenoid cavity. They are intrinsic shoulder muscles, the tendons of which gather together to “cuff” the shoulder joint and provide stability for our complex arm movements. The 4 muscles are referred to as the SITS muscles (supraspinatus, infraspinatus, teres minor and subscapularis) and all of them, except for the supraspinatus, mainly function to assist with rotation.
The supraspinatus (which I suspect Craig severely tore) is a band of muscle, which occupies the top fossas of the scapula and attaches to the middle (greater tubercle) of the humeral head .The supraspinatus abducts the arm with the help of the deltoid.
The infraspinatus lays in the fossa below the spine of the scapula and is partially covered by the deltoid and trapezius. It is a strong lateral rotator or the upper arm bone.
The teres minor is a long lateral muscle that runs below the infraspinatus on the lateral border of the scapula and assists with lateral rotation. It also attaches to the head of the humerus on the greater tubercle, next to the infraspinatus.
The subscapularis is a thick muscle that lines the anterior wall of the scalupa and forms part of the posterior wall of the axilla. It’s the primary medial rotator of the arm and assists with adduction and also attaches to the humerus,
These 4 rotator cuff muscles all work together and hold the humeral head in the glenoid fossa; and assist with the actions of abduction, adduction, lateral and medial rotation. Traumatic injury is very possible, especially with the supraspinatus, and degenerative tendonitis is also quite common- especially with repetitive use above the horizontal line. Degenerative tendonitis prevents a person from smoothly lowering an abducted arm, and a tear of the supraspinatus will prevent initiation of abduction.
With Craigs permission I will update us with news of his rotator cuff.