In my hospital job, it is customary for my manager Nora to print out letters of appreciation that we occasionally receive from our patients. In honor of that tradition, and as yoga teachers we know it is even less frequent, I am posting a recent email I received from a student. To all the yoga teachers and health care providers, take it in.
Last week I taught a chair yoga class at Publishers Clearing House in Chelsea as part of their corporate wellness day. Dues to space (and time) limitations we ended up doing two 30-minute sessions. Although not easy to interrupt deskwork fever to do a mindful yoga practice in the middle of the day, the participants were elegant, thoughtful and positive in attendance and approach. As expected, lots of very tight hamstrings, hip flexors, rounded shoulders and tight pectorals. Computer time breeds a collapsed chest and tight neck and shoulders, so the back/neck/chest stretches were helpful and immediately helped to re-calibrate posture. Additionally, often the fancy ergonomic office chairs are don’t provide enough lumbar support so an addition cushion is helpful. Literally, even a 10-minute yoga breather can break up the physical stress and re-pattern towards better alignment. A cheat sheet of yoga poses were provided.
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.
Brene Brown, in her CD series called The Power of Vulnerability, discusses 10 guideposts for what she calls “wholehearted” living; cultivating authenticity, cultivating self compassion, cultivating a resilient spirit, cultivating gratitude and joy, cultivating intuition and trusting faith, cultivating creativity, cultivating play and rest, cultivating calm and stillness, cultivating meaningful work and cultivating laughter song and dance.
Though all of the topics are rich and resonate with meaning, I have to confess that two of them really surprised me, and in turn, that surprise surprised me! How could I – a dancer, music lover, parent and Occupational Therapist be so surprised and utterly charmed that cultivating play and rest and cultivating laughter, song and dance make it to the top ten list?
And out of that list, the one that I think surprised me most of all was the word play. In Occupational Therapy literature, play gets lumped under the category leisure time, which immediately sucks some of the fun out of it. Leisure time can be any meaningful activity: watching TV, cooking, exercising, dinner with friends – all great to do but maybe different from play. For me, the word play conjures up fun, laughter, connectivity, losing sense of time, wanting to do nothing else but what you are doing, enjoying the moment fully and with abandon.
Play is fun, and leisure time is meaningful time spent.
How do we remember to play? What if it is not meaningful? Are we allowed to spend time not doing something for a purpose?
Brene Brown talked about making a pie chart with overlapping play areas amongst her family members to see which of their play experiences could be authentically shared. We haven’t done that yet, but as the summer floods in the season feels right to think about how we can, with a sweet push, fill it with play. And because my running list of meaningful work stomps on my play gene, I am trying to approach play not as a therapist, mother, or productive member of society, but with a deep exhalation to remind me that its ok to relax and cultivate play for myself.
I like mornings – our energy and brains are clear and the day spans before us, however, I have never been a “morning” person. Once up, there are the daily list of things to do and the race to leave the house. If I wake up late, I am rushed and frantic and settle down over time. Finally these past few weeks since returning from my yoga retreat I have changed my pattern, which has felt thrilling. My new ritual involves getting up a full hour earlier, making coffee, feeding the birds, spreading out my yoga props and doing 45 minutes of yoga before the house wakes up.
Sometimes I listen to NPR or sometimes in full silence. I can begin fast or spend 10 minutes lying on blocks. The best of all is when my partner wakes up with me, and we practice yoga perpendicular to each other alongside the kitchen table. He diligently looks through the books and though a beginner doesn’t pepper me with questions. I give him verbal cues infrequently and usually only when he looks like he might try to perform a regrettable feat. The household slowly wakes up and a positive mood has been established.
Here is a ten-minute version:
Lying on two yoga blocks; place one behind your upper back and the other underneath your head (the head one should be higher then the back one) and breathe into your chest area while rolling your shoulders towards the floor. Legs can be bent or straight.
Then stand up and place your hands on the kitchen counter and walk your feet backwards (hip width apart or wider if your hamstrings are tight) until your chest is parallel to the floor (or as close as possible) and breathe while you bend and straighten your knees. Try to reach your sitting bones back behind you as you feel the stretch in your chest area, back and the back of your legs.
Start your day!