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How Common Are Injuries In Yoga Adjustments?
Hands-on adjustments or assists are common in many Western yoga asana classes. Injuries in yoga adjustments are a common topic of discussion in the yoga community. Depending on the particular style of yoga and the background of the teacher, adjustments or assists might look something like spotting in gymnastics, they might more closely approximate a form of bodywork or they might just be a light touch. The intention of adjustments is to help practitioners find their way kinesthetically toward the expression of a posture that they might not initially be able to find on their own. This might mean nudging someone farther forward in a forward bending posture or it might mean helping someone balance in headstand, eventually giving them the strength and confidence to come up on their own.
There are very vocal advocates for the benefits of receiving adjustments in practice and there are those who feel strongly that adjustments should have no place in the yoga room. There is essentially no published research to provide a defense for either position.
This post will share the results of our yoga survey regarding what practitioners are experiencing in their practice related to hands-on adjustments and assists. We now have some data that we hope will help further the conversation about injuries in yoga adjustments.
Methods: A Quick Lesson on Statistics
Statistical analysis, in the most general sense, is a method of calculating the likelihood of one particular outcome in a situation given a specific set of circumstances. There are lots of different formulas for making statistical calculations; different formulas are appropriate in different situations. The specifics are well beyond the scope of a blog post. What’s important is that we explain enough of the methodology that you can understand what we mean when we describe the results of our survey below. You’ll see within the text, this symbol: p=some number. This value, referred to as the “p-value” is the probability that variables in the survey are unrelated; if the p-value, is less than 0.05, then we say that the two variables are related.
Context and Practice Experience
Again let’s note the context in which these experiences with hands-on adjustments are being reported. You’ll remember from our survey summary post that the greatest majority of our respondents were long-term practitioners (4+ years of consistent practice), female, and between the ages of 31 and 55 at the time of the survey. Most respondents practiced for 60-90 minutes in a single session either at a studio or at home.
Experience in Hands-On Adjustments
What experience do practitioners report regarding the impacts of physical adjustments/assists on their yoga practice?
Nearly all respondents (97% ) said they had received hands-on physical adjustments in class, leaving only 2.9% who had not (n=2610). Most respondents (n=2530) found hands-on physical adjustments to be “very helpful” (71.9%). Another 19.5% found them to be “somewhat helpful”. Only 3.3% found them to be either somewhat unhelpful or very unhelpful.
Of respondents who reported that yoga had been part of their healing process from a pain or injury, about half (53.9%) reported that hands-on physical adjustments from a teacher had contributed to their healing process (n=2076).
Of the 2620 total practitioners who responded to our question about experiencing an injury during yoga practice, 284 (11%) reported that they were injured while receiving a physical adjustment. Of the 1422 people who were injured at least once during the time that they have been practicing yoga asana, 972 people (68.4%) said they were not receiving a physical adjustment when they were injured, while 316 (22.2)% reported they were receiving a physical adjustment when they got injured (n=1422). An additional 4.6% said they were being verbally adjusted when they got injured and 4.8% didn’t remember the circumstances of the injury. Another way to look at the same question is this: 2534 respondents reported they had received a hands-on adjustment in a yoga practice, while 316 reported they had been injured while receiving a hands-on adjustment. 284/2534 gives us 11% of those who have ever received a hands-on adjustment who have also been injured.
Those who reported receiving hands-on yoga adjustments during their lifetime of practice (n=2610) were also more likely to have reported experiencing at least one injury during the time that they have been practicing yoga, but this relationship was only moderately significant (p = .0209). Those who reported practicing Ashtanga yoga were more likely to also report getting injured while being adjusted than those who did not report practicing Ashtanga. However, this should be understood in the context that hands-on adjustments are likely used more consistently in this style, as they are part of the teaching tradition. We could not directly compare the percentage of respondents who were injured in an adjustment in each specific style of yoga because the question on practice style allowed for multiple answers. Many respondents marked more than one practice style, so percentages would not have represented discrete groups. Additionally, it is important to remember from our negative experiences summary post, that overall rate of injury, that is, the total number of injuries experienced over the total number of years that someone has been practicing was low compared to a number of other activities. (Average overall injury rate of respondents was 1.6 injuries experienced over the total number of years of practice.)
We did find a relationship between those who reported injuring their lower back (p=.0229) or their upper back (p=.0124) and also reporting getting injured while being adjusted, however, this relationship was only moderately significant. There was no relationship between reporting a knee, shoulder, foot, ankle, or hip injury and reporting getting injured while receiving an adjustment.
Poses and Injuries in Yoga Adjustments
What poses were most commonly being performed when someone was injured while being adjusted?
Many different poses were reported with regard to the experience of injury while receiving physical adjustments. While you can peruse an abbreviated table above for numbers of respondents that reported an injury while being adjusted in a specific pose, a better question is what does this mean? Are adjustments “good”? Are they “bad”? Are they “good” some of the time, “bad” some of the time, and if so, how do we know the difference?
If you want to learn a process for working with injuries you should definitely check out the online injury workshop. It teaches you a process of how to assess, modify, and work with injuries.
Rather than try to answer this question and label adjustments as inherently “good” or “bad”, this seems a good place to recognize that respondents reported adjustments as contributing to both experiences of healing and injury, with 7% of individual respondents (n=1129) actually reporting having had both of those experiences themselves. This then suggests that this is a place for a conversation as a community about when and how we might use adjustments to support the process of healing and how we might reduce the chances of adjustments that have negative impacts. With this as our goal then, let’s take a closer look at the information that we have gained from this survey to help inform our choices about when, how, and if we apply hands-on yoga adjustments.
What you might notice in the table below is that the poses listed could be more generally lumped into groups: 1) poses that take the body to the end of range of motion for a joint, 2) poses that have potential to put pressure into a joint or muscle attachment that is anatomically more tenuous in the body, and 3) poses where balance and/or momentum is involved and there is the potential to fall. Of course, many poses could fall into more than one of these categories.
Poses that Take the Body Toward Ends of Range of Motion
In the first category, we have a pose like supta kurmasana, which takes the body to the end of range of motion for forward bending by bringing the torso, not just to the legs, but all the way through the legs, if you’re doing the full expression of the pose. A second example of a pose that falls into the first category is kapotasana as done in the Ashtanga Vinyasa Yoga system. This backbend takes the body nearly to the end of range of motion of back bending by asking the practitioner to lengthen tissues along the whole front of the body allowing them to reach the hands behind them to their feet.
Postures with Potential to Put Pressure into Anatomically Tenuous Areas
In the second category, we have all of the forward bending postures. You’ll notice there are many variations of forward bending postures at the top of this list! In this case, what was most commonly reported by our respondents as injured in any variation of forward bending was the tendinous attachment at the sit bone. This kind of injury is not at all unique to yoga. In fact, there is a growing amount of research in the area of sports research on why this attachment is tenuous and potentially prone to injury in all kinds of sports and activities! We’ll discuss forward bending and sit bone pain more specifically in this post (Forward Bends and Hamstring Injury).
We also have postures in this second category that have potential to direct pressure into one or both knees. I’ve already written quite a bit about why the knee joint is tenuous in its position in the middle of the kinematic chain of the leg where other joints can impact it from either direction or both (You can check out my new Online Lotus Workshop). What do you think might happen in a posture where one end of the kinematic chain of the leg is prevented from moving and pressure is put into the chain from the other end? For example, if you’re sitting on the foot, as in Janu sirsasana B, and pressure is put into chain from the hip end, there is potential for that to travel into the knee since the foot is prevented from moving to allow the knee joint to adjust.
The third category perhaps requires the least anatomical explanation. In this category, we have poses like headstand or visvamitrasana (a version of side-arm balance). Whenever we’re learning to balance in new ways, there exists the potential to fall. With that, is the potential for the adjuster who was spotting the pose not to catch the person who fell for whatever reason. This was the least common type of injury reported in the context of also being adjusted or assisted in a posture.
So now we’ve taken a quick look anatomically at what has the potential to cause injury in hands-on adjustments. The other piece of this that we should consider is what’s going in the nervous system.
Adjustments and the Nervous System
The relationship between the nervous system and the muscular system becomes particularly important when we are talking about movements at the ends of range of motion or movements that have the potential to put pressure into anatomically tenuous areas of the body. When we put any type of stimulus into a person’s body, what we are really doing is putting that information into their nervous system. This information is processed, reacted to, or responded to. Depending on the joint and the tissues around it, adding to range of motion may be very small distances (say, the shoulder), or potentially larger (hip). In other words, speed and force need to adapt according to the joint, it’s position, and the tissues surrounding it.
Doing any type of hands-on yoga adjustments requires sensitivity on multiple levels. From the teaching or adjusting perspective, there is a listening or observation, an assessment of the totality of information being observed, and an appropriate response to that observation and information.
What we as teachers are often unaware of are our biases. We all have a preconceived idea or story about how the pose is supposed to be done. This is based on prior experience and the system of yoga asana we are teaching. It’s often our observation of a student doing something that is not inline with our own story of how the pose is supposed to be done that initiates our desire to go to them and do or say something. If it’s reactive, then we may be dropping into the simplified version of teaching, which is trying to “fix” something. However, a response would be to process the context in which this person is doing the pose. For instance, what level is their practice, how well do we know them, not to mention the type of class, or what type of body they have, etc.
I say all of this, because if you are not responding to all of it, you are often just reacting to your own bias. At these moments of doing the adjustment, the student or their body, so to speak, picks up on this. This is critical because if the student or their body resists a more physical adjustment, the chance of injury goes up significantly. (This observation is based on my experience, not on the survey results.)
As I discuss in my adjustments video, when you are offering an adjustment, ultimately, you are trying to tune into the information that the student’s body is giving you on a moment by moment basis AND you are responding to that on a moment by moment basis. What needs to get out of the way is your story that you are fixing them, making it right, which may be based on something other than what is happening in that moment.
When students are in a state of resistance, their muscles are engaged in a way that will simply make it harder to deepen the posture, or even realign it in some way. Although there are some arguments for engaging tissue at the end of range of motion, that is very different to trying to adjust someone when they are actively resisting. In this case, you are fighting the tissue and the tension created from being engaged as a reaction. This seems to be the most common place for injury to happen.
The “therapeutic edge” is itself a bit of a catch-22 in my experience. Forget adjustments for a moment. The edge of feeling and/or sensation (often the end of range of motion or end of pressure being placed on tissue) of the student/client is often a place where we begin to see change or response in the tissue. That is, positive change.
It is also at this same edge that the potential for injury increases. Going too far beyond that edge is basically called injury. When you take someone beyond that “therapeutic edge” you are at the ends of range of motion or sensation. If you keep moving past it, you can easily cause injury or add pain to the system and it will react or respond.
In the case of adjustments, the body typically responds with contraction as a protection mechanism. If you continue to put pressure on the tissues, you are essentially fighting rather than working with the system.
For example, one student shares this description of their injury: “Pulled muscle/tendon when being pushed just a bit too far and I tensed – which probably partially incurred the injury”
An adjustment that might work well for us when in the context of working with a teacher who is familiar to us and with whom we have an established relationship of trust, might backfire if it is applied by someone who is unfamiliar to us, even if they are a skilled teacher. Our availability in a particular situational context to “accept” an adjustment affects how it is received by our nervous system. This affects the number of injuries in yoga adjustments reported.
Sharing The Experiences Of Practitioners When Injured In An Adjustment
Below we share a range of students experiences when they were injured in an adjustment. Several themes were represented in our survey in the open-answer descriptive responses that respondents gave to describe the circumstances of their injury. The first group of quotes reflect the importance of student-teacher relationship when giving an receiving adjustments. The second group of quotes reflect the importance of experience when giving adjustments. The third group of quotes reflect the wide use of hands-on adjustments in multiple styles of yoga. While adjustments are part of the traditional teaching method in the Ashtanga vinyasa system, they are widely used in other styles of yoga as well.
These experiences reflect the importance of student-teacher relationship when giving adjustments!
“Pulled hamstring – was practicing with a cover teacher and she pushed me a bit too far in utthita hasta padangusthasana pulled the hamstring attachment at the top of my left leg/buttock.”
“an assistant in a workshop gave me a too-strong adjustment using a strap, and tipped my left femur slightly out of the socket.”
“Adjustment from a teacher covering who didn’t know my body. Paschimottanasa – too strong on my lower back.”
“I was attending a workshop of a senior, internationally known teacher. During asana he came came over to “assist” me to go deeper into a deep seated twist pose (Bharadvajasana ). without asking permission. I immediately heard a loud pop in my knee. This adjustment resulted in a major tear in my meniscus.”
“an adjustment in ardha baddha padma paschimottanasana that was too deep for my capabilities at the time, from a teacher that didn’t know me during a week long workshop.”
“Trying half lotus with not enough hip opening. Teacher was not my main teacher, it was at beginning of my ashtanga practice.”
“It was a misunderstanding about an adjustment: A teacher (not my main teacher) helped me drop back with a belt around my hip and I did not feel particularly safe doing this, but I did not want to discuss.”
“Started as a hamstring tendon injury when adjusted in standing forward fold by guest teacher”
“Hamstring injury as I was being helped on a standing pose by a substitute teacher”
“An adjustment that was brutal in kapotasana by a certified teacher! It was the first time i had practised with this teacher and he did not watch me do kapo first nor ask me how far I usually went.”
“Hamstring injury as a result of an adjustment that went too far. This adjustment was done by another teacher while I was traveling, not my regular mysore teacher”
“Non experienced stand in teacher adjusted me in Marichiasana D”
“Adjusted at a workshop and she cranked my shoulder”
“I was practising with an unfamiliar but reputable, experienced teacher. I had informed them of my chronic neck injury. At the start of the practice I was told I could “let go of my neck injury now.” I was given a very deep adjustment in Pasasana at the end of the practice I was lying down in savasana; went to roll onto my right side; felt my neck injury ‘unzip’ down the back of my neck. I was encouraged to continue practicing on subsequent days, pain just hit worse ended up in casualty”
These quotes reflect the importance of experience when giving adjustments and the need to use caution when first learning to share adjustments.
“Tore calf muscle in leg during adjustment by fellow yoga teacher trainee”
“Students did adjustments to each other the way teacher said in My Case, I was in baddha konasana and fellow student put her weight to My back and pushed My legs toward floor. Stretch was too powerful.”
“I had an assist in urdhva dhanurasana that injured my lower back at a workshop that had people assisting other classmates. One person pulled on my hips the other pulled on my upper back/shoulders.”
“I was adjusted in supta kurmasana by a fellow practitioner and my collarbone popped”
“I was in an ashtanga class in India, and I didn’t realized that in this class people doing the TTC with this teacher were about to adjust. I was in paschimottanasana and I was almost reaching my head to knees but it wasn’t my aim in this class , so this girl pushed my without being careful. I didn’t feel anything till I cool down when the class finished and as soon as I took some steps it hurt so much! And I know it was that adjustment. My pain continued for 8 months on and off”
“Overdoing it on the first day of teacher training, in particular doing poses intentionally wrong in order to allow a partner to correct you.”
“Many years ago I attended workshop for learning hand’s on postural adjustments and was paired with a beginning yoga student who was taller and stronger than I, and I was moved into a misaligned adjustment and held there.”
“Was being adjusted in half lotus in teacher training workshop”
These quotes reflect the wide use of hands-on physical adjustments in many styles of yoga practice.
“I was over adjusted in a Yin class, and at the time was very new to Yin, the teacher kept going on about yoga being pain, so I ignored the pain and tried to breath through it. My knee swelled up afterwards and then 3 months later was diagnosed with a torn meniscus and had it operated on. Never been back to that teacher !”
“I was the demo for a Iyengar teacher in a module during my 500-hour teacher training. I was asked to demo triangle pose, and the way I was asked to do it aggravated a long-standing injury that, until then, I’d managed pretty well with my own practice. (Not an Iyengar practice.)”
“I was in a Bikram class (that I was not a regular student of ) . The teacher came over and lifted my leg to my face in Uttitha Hasta Padangustasana without even speaking to me or knowing my history/practice.”
“Decided to try an anusara class with a well known teacher. She had asked us to do chaturanga in a way I had never been instructed. She had a student demo it, then she came around to the rest of the students to help us do it ‘correctly’. She was trying to move my body in a way that it did not want to go. I am not sure it was her inexperience or the method, but I hobbled out of the studio w/tremendous back pain. I’ve always had a sensitive lower back and this method just aggravated it more.”
“I broke my left ring finger by incorrectly landing on it while trying to jump into bhujapidasana in a Rocket Yoga class. The teacher, who was trying to teach me this entry into bhuja, said she was going to catch me and not let me land on my face. Not only did I land on my face, my finger crumpled unnaturally and it broke”
“Working on Maltese Cross position with assistance of teacher, Adductor muscle/tendon of Right inner thigh “Popped” very painful and took many months to heal, still feel twinges 4 – 5years later”
“I practiced the head stand with my Iyengar teacher but my physical strength was not ready for it. So I got two slipped disks in my cervical spine which had to be operated on.”
“The teacher came to adjust me in standing compass pose and when he lifted me there was a loud pop noise (followed by my scream). I couldn’t walk after class and an MRI revealed my left ischial tendon was torn”
“I was in halasana, in an Ashtanga workshop. The assistant who was NOT an Ashtanga teacher but an Iyengar teacher came up behind me during the posture and shifted my hips quite violently “straight” with her hands. I was not aware she was going to do this as I was inverted and looking down my nose. It was shocking and abrupt. I experienced an immediate dislocation of the sacrum on one side, and lots of pain for months/years!”
“A 40 year Iyengar teacher asked for volunteers to do an assisted full backbend to standing sequence. I was the backbender. When the two assisters pulled me up at the instruction of the Iyengar teacher they snapped my spine in the upper thoracic region. We all heard it snap then I became dizzy. Then it passed. Two hours later I began to have trouble moving.”
I teach adjustment workshops, and I have produced a four hour DVD on this subject. At the time, I did have reservations about the production of that video and whether or not it was appropriate to even try to teach such a subject through this medium. In the end, I realized that I would rather be a positive part of the conversation because I believe I have something valuable to add.
As I ask in workshops, and on the DVD: What is your intention as you approach someone to do a Hands-On Adjustment? This may be the single most important factor in determining the success or failure of the adjustment.
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David summarizes research which evaluates physical effort needed to do common standing yoga postures and how that effort compares to walking.