Friday Q&A: Sacroiliac (SI) Joint Injuries

Q: I have been having problems with low back pain caused by my sacroiliac joint (SI joint) going out of alignment. It seems like something I'm doing in my yoga practice is making it worse. I’m looking for both techniques to snap the sacrum and pelvis back into place and alignment, and advice on how to prevent this from happening. I would appreciate any help with this. I want to keep practicing!

A: I asked Baxter to answer this question because he’s the back care expert (and MD), but since I’ve had this problem myself, I know a little something about it. And maybe even have slightly different advice than Baxter. So Baxter asked me to preface his answer with my own.

First of all, this is a common injury for dancers and yoga practitioners, though not for the general population. In general, forward bends and twists take the sacroiliac (SI) joints out of alignment. Janu Sirsasana seems particularly bad. Backbends can put the joints back into proper alignment. So for now, I'll just suggest that at the end of a practice that includes forward bends and twists (even standing versions of these) that you include some kind of supported backbend before Savasana. Stay in the pose for at least three minutes. You want to restore the curve in your lower back. For example, Bridge pose with a block under the sacrum or even Legs Up the Wall pose with a bolster, where your lower back is arched over the bolster, can help restore the curve. (I’m recommending supported backbends because active backbends—which Baxter recommends below—at the end of a forward bend practice reverse the quieting effect of the practice. This is not really an issue for twisting practices. Regardless, you might try both as everyone is different.)

I also recommend that you read articles on the topic by Roger Cole on the Yoga Journal web site (see Protect the Sacroiliac Joints and Practice Tips for the SI Joints). I’ve learned a lot from him over the years, and have taken his workshop on the SI joint.

Finally, as wonderful as yoga is, it isn't necessarily the answer to everything, so you may need to take time off from certain poses or your asana practice entirely to heal before resuming practice. I, myself, as well as other yoga friends, have had good results from going to a chiropractor who realigns the sacrum manually. My chiropractor is also a yoga teacher—that's the perfect combination if you can find one. 

Now for Baxter’s reply.

—Nina

A: It might be helpful to our readers to define what we mean by “sacroiliac dysfunction.” Typically, the joint between your sacrum bone and the two halves of the pelvic bones meet at the right and left side of the posterior pelvic area and form a fairly firm, barely moveable joint called the sacro-iliac joint, or SI joint for short. 

The only exception to the “barely moveable” concept is for women about to give birth. In order for the safe delivery of the baby’s head and body, the joints of the pelvis, including the pubic symphysis in front, have to be able to move. The pregnant woman’s body produces a hormone, relaxin, which allows the ligaments around the joints to loosen and permit more movement than normal. Once the baby is safely delivered and breast feeding is concluded, the production and release of relaxin slows and disappears and the SI joint regains its previous firmness.

As Nina pointed out, seems there are a few groups of folks more likely to loosen one side of the joint. These include gymnasts, dancers and yoga practitioners. And indeed forward folds combined with twists seem to be regular culprits. These poses create a torquing action through the pelvis that can overstretch the ligaments and result in more mobility on one side. It is unusual, in my experience, to have someone with both SI joints hypermobile, but I have seen it at least once before.

And indeed, Roger Cole has written some very good articles on this topic, and leads workshops on the topic around the country, which I have attended and can highly recommend. In addition, Judith Lasater has an article in the Yoga Journal archives on her bout with SI joint dysfunction, how yoga brought it on, and how yoga helped her heal it (see Out of Joint).  She also has some discussion in her book, “Yoga Body” on the particulars as well, if you want to dive a little deeper. After reviewing the chapter in her book on the pelvis, I found a 1991 review of all the research to that date on intra-pelvic joint movement, including SI joint movement.  It seems there is some evidence for minor but distinct amounts of normal healthy movement at the SI joints, but a decent amount of confusion still existed at the time of that study.

As for asana recommendations, I like active backbends, especially Locust, but doing a variation Roger Cole teaches where you have the legs parallel, you strap the ankles and push out against the strap as you lift the legs up. He also recommends doing some asymmetric propping with sandbags, but I have found the symmetric version effective for some students.  And I’d put a block between the knees for active bridge and also consider strapping the thighs without a block and push out against the strap as you go up. I believe the theory is that you are creating some lateral space so that the SI joint that is misaligned can pop/slide back into place. These are only two of a whole slew of pose variations that Roger shares in his workshops, so look for the chance to study with him down the road.

And don’t discount the benefit of working with a good physical therapist, as I have had students who were taught some effective simple adjustments they could do to get the SI back in good alignment. And as Nina has mentioned, I have had some students work with chiropractors and osteopathic physicians who got adjustments that resulted in SI re-alignment.  Ideally, you would not need to do this very frequently.

This is certainly a hot topic, so keep your eyes and ears open for new developments on the issue of SI joint dysfunction.  Thanks for your question!

—Baxter

Friday Q&A: Scoliosis

Patterns in the Sand by Michele McCartney-Filgate

Q: Scoliosis. I have a mild case of it and find that twists and side bends make my back feel good. Any other advice? When I look at my students doing forward bends, it seems that a lot of them have one side of the back of the rib cage that protrudes higher than the other side. Just how common is scoliosis anyway?

A: The conventional wisdom when working with scoliosis is to apply some therapeutic principles to the spinal structural changes. They include to lengthen the concavity, strengthen the convexity, and to try to neutralize the curvature in asana. This isn't as easy as it sounds because most scoliosis patterns that are in an "S" shaped curve will have a more pronounced primary curve and then a compensating secondary curve.

To successfully work with your own scoliosis you need to first know if the curve is from postural imbalances or from structural changes. The quick way for this to be screened is to have someone watch you as you bend into Standing Forward Bend (Uttanasana). If the curve worsens, then it is structural. If the curve evens out, then it is most probably postural overlay. But the only conclusive way to know if you indeed have scoliosis is to have an X-ray of your spine from head to tail. A skilled radiologist needs to read it to measure the curve.

That said, your observation that twists and side bends make it feel better are reinforcement that you are probably stretching your concavity. There is a way that spines move that is unconscious (meaning it just occurs) and that is the law of side-bending and rotation. In a neutral spine (like Mountain pose or Tadasana,  side bending and rotation occur to opposite directions (we are talking about how the vertebra individually are moving. So, that is why in Triangle pose (Trikonasana) you are asked to rotate your torso over a fixed pelvis. But in forward bends or backbends, spinal movement changes. In this case rotation and side-bending occur to the same side (picture One-Legged Forward Bend or Janu Sirsasana). So this is where the confusion comes in because you need to move the spine differently depending on the asana you are practicing. Also the scoliotic spine is not symmetrical and there are elements of side-bending and rotation already present so when you bend forward in Standing Forward Bend (Uttanasana), you are increasing the spinal rotation; this is why the curvature worsens.

So it depends on how much information you want or need to apply to your yoga practice. Some teachers recommend doing your poses three times, starting and end a pose with the problematic side, that is, the side for which twisting is more difficult. I would recommend you obtain Elise Browning Miller's yoga DVD on scoliosis, and, if you live in the Bay Area, try to take her workshops on yoga and scoliosis because they are excellent. See http://www.ebmyoga.com/.
—Shari

A: Regarding the prevalence of scoliosis, out of every 1000 children born in the US, 3-5 will develop an abnormal curvature of the spine serious enough to require intervention. The scoliosis usually first shows up during growth spurts, especially around puberty. In 80-85% of the cases, the cause is unknown, and so it is labeled “idiopathic scoliosis.” Most of these students will not require serious intervention, and yoga could be a great way to address the spinal curve and twist.

Recently loss of bone density has been shown to cause lateral deviations in the spine that may contribute to the onset of scoliosis in postmenopausal women. Estrogen hormones are very important for the maintenance of bone mineral density, and during menopause, the normal levels of circulating estrogen decline. So there is increased risk for losing bone density, and therefore an increased risk for degenerative scoliosis. Recent evidence also suggests that the development of scoliosis in postmenopausal women is much higher than in juveniles and adolescents. One has to wonder if there was a mild scoliosis present, perhaps undiagnosed, that becomes more apparent at menopause. Also, kyphosis, or dowagers hump, is well know to arise at this time as well, and is likely a combination of posture and osteoporosis.

Other stats on scoliosis:

• Scoliosis curves measuring at least 10° occur in 1.5% to 3.0% of the population
• Curves exceeding 20° occur in 0.3% to 0.5% of the population
• Curves exceeding 30° occcur in 0.2% to 0.3% of the population
• Small spinal curves occur with similar frequency in boys and girls, but girls are more likely to have a progressively larger scoliotic curve that will require treatment

And I agree with Shari's insights on scoliosis and also recommend Elise Miller's DVD and workshops around the US on yoga for scoliosis. One example of how one approaches this would go like this: if the main curvature is to the right side of your thoracic spine, that is, the convex bulge is easily seen in Standing Forward Bend (Uttanasana) as a skyward prominence on the right side of the back rib cage, you would likely approach asymmetrical poses like Triangle differently going to the right side and to the left side. When going to the right side, focus on spreading from the spine around the side of the ribs toward the front of the chest, something Elise calls "de-rotation."  When going to the left side, focus on lengthening the left side of the waist and torso, from the left hip crease to the left armpit. No specific attention would be directed at the right-side prominence on this side. This same principle could be applied to other poses such as Extended Side Angle, Warrior 2 pose, and Half Moon pose. The principle may change with symmetrical poses, as Shari said.

Another good East Bay resource is Sandra Safadirazieli, who trained with Elise, has been working with her own scoliosis, and offers classes at Piedmont Yoga Studio on an ongoing basis. Teachers from other parts of the country should chime in with recommendations for other teachers and workshops.

—Baxter

Featured Pose: Simple Chair Backbend

by Baxter and Nina

Another one of our five essential office yoga poses, the simple chair backbend is the perfect antidote to the typical postural habits of slumping forward that we develop from sitting all day at our desks, in cars, and airplanes, and from the many everyday activities where we are bending forward, such as gardening or washing dishes.

The basic back-bending shape re-establishes the natural curve of your lower back, correctly aligning your spine in its natural curves, which helps to keep your back healthy. The backbend also lengthens the front of your body, allowing many of us to breath in with greater ease. It helps release stress from your upper body, especially the upper chest. And while stretching the front of your body, the pose strengthens your back body muscles, which tend to be overstretched and weak if they are ignored.

Because backbends in general tend to be uplifting, you may even find this pose helps encourage a more positive mood as you take deep inhalations and exhalations.

The pose can be done almost anywhere. Although a chair without arms is preferable, you can use almost any chair, as long as the back is low enough for you to rest your shoulder blades on.

Baxter prescribes this pose for:

•    Kyphosis of the upper back
•    Chronic lower back pain
•    Head forward syndrome
•    Scoliosis
•    Carpal tunnel syndrome (when symptoms are coming from the shoulders)
•    Sore back from traveling or sitting at your desk
•    Depression
•    General digestive concerns (such as heart burn and acid reflux)

Instructions: If possible, try to find a chair with a back that touches you near your lower shoulder blades. Then move your chair away from the wall or other furniture so you leave some space behind you.

Next sit on the chair, either it the center (if you’re shorter) or near the back (if you’re taller) so the soles of your feet are flat on the floor. If you’re small, you might need to add some support on the chair seat and/or underneath your feet. Align your feet below your knees, with your thighs parallel to the floor. Now, reach your hands around to grab the lower sides of the chair (where it meets the seat) or, if this is not possible, rest your palms on the back of the chair seat.

Root down through your feet and arms, lengthen up from your tailbone to the crown of your head, and mindfully arch your spine up and back until your upper rib cage touches the chair back and rests there lightly. Keep your chin tucked toward your chest.

If you are very comfortable deeply bending your neck, you can take one or both hands behind your head for support as you allow your neck to follow the backbend of your spine, as shown below.

As you inhale, encourage the lift and arch of your spine. As you exhale, maintain your lift and arch. Continue for four to six breaths, working your way up to 12 to 16 breaths as you become stronger in the pose. Come out with a strong exhalation.

Take a moment to notice how you feel. You should feel stretched, strengthened and alive, not painful and miserable. If you experience any pain afterwards in your neck or back, this backbend variation might not be for you.

Cautions: Not all forms of low back pain (such as, spondyolisthis, facet arthritis, spinal stenosis or disc herniation) will be helped by the chair backbend, so you have a back condition, check with your doctor before doing this pose. If you have cervical spine or neck issues, be careful with the position of your neck, keeping your chin tucked toward your chest as you go into the backbend. If you have osteoporosis, adding padding to the top edge of the chair so there is less pressure on your spine is recommended.

"I think I have sciatica"

by Baxter

If I had a dime for every time I have heard this from friends, students and patients, I would be doing all right! Usually, any time someone gets a pain in the back that travels below the buttock, they believe they are suffering from sciatica. And some of them may be right, but others could have something else going on. So before we go any further, let’s step back and try to define what sciatica is, which is easier than that might seem, as it is really a symptom, not a medical condition or disease. What that means is that even if you do have sciatica, you are just at the beginning of a journey to find out the underlying cause of you symptom.

Sciatica gets its name because of the relationship to one of the body’s important nerves, the sciatic nerve, which is really made up of several nerve roots from the lower lumber and sacral region of the spine. These separate nerve roots emerge from the sides of the spine and join together to make a bigger nerve that travels down the back of the legs all the way to the feet. It has a couple of jobs: it supplies sensation to the muscles of the backs of the knees and lower legs, and it also provides sensation to the backs of the thighs, part of the lower legs, and the soles of the feet.

Let’s take a look at what the NIH, National Institutes of Health (see here) have to say about sciatica:

Sciatica refers to pain, weakness, numbness, or tingling in the leg. It is caused by injury to or pressure on the sciatic nerve. Sciatica is a symptom of another medical problem, not a medical condition on its own.

Sciatica usually affects people on just one side of the body. And it turns out that the "symptom" called sciatica is actually a constellation of other symptoms. Here’s what the NIH has to say about that and the pain associated with sciatica:

Sciatica pain can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe enough to make a person unable to move. The pain most often occurs on one side. Some people have sharp pain in one part of the leg or hip and numbness in other parts. The pain or numbness may also be felt on the back of the calf or on the sole of the foot. The affected leg may feel weak. The pain often starts slowly. Sciatica pain may get worse:

• After standing or sitting
• At night
• When sneezing, coughing, or laughing
• When bending backwards or walking more than a few yards, especially if caused by spinal stenosis

Okay, so far so good.  But that, again, is a pretty broad set of symptoms that could account for this thing we are calling sciatica.  So, if we are going to put our finger on the underlying cause, what are the most common culprits?

A few of the more serious and common causes include a slipped disc in the lower lumbar area of the spine, Piriformis Syndrome (a condition associated with a deep muscle in the buttock area beneath the gluts that comes in contact with the sciatic nerve as it heads down the leg), pelvic injury and fracture (which could include sacroiliac dysfunction, a not uncommon problem for yoga students) and tumors.

Interestingly, a lot of cases of sciatica will resolve on their own without a lot of testing or heavy duty treatment. In the old days, they used to recommend bed rest for these kinds of symptoms, but we know now that it is prudent, after a brief period of rest, no more than a few days, that gradual return to everyday activities can be helpful, with gentle spinal movement and core strengthening very helpful for recovery. This is, of course, one way yoga can help. In fact, yoga is an excellent way to promote gentle spinal movements, safely strengthen the abdominal area and the lower back muscles, as well as stretch several muscle groups that are associated with general lower back pain that could include sciatica, such as the psoas and the piriformis muscles.

 In addition to acute treatment with over the counter meds like ibuprofen and acetaminophen, as well as ice and heat, the NIH also makes the following recommendations for early treatment:

Bed rest is not recommended. Reduce your activity for the first couple of days. Then, slowly start your usual activities after that. Avoid heavy lifting or twisting of your back for the first 6 weeks after the pain begins. You should start exercising again after 2-3 weeks. This should include exercises to strengthen your abdomen and improve flexibility of your spine. (Go yoga!)

If your symptoms are not improving, you are having weakness in one leg, you noticing a foot is kind of drooping when you walk, or you have difficulty controlling your bowels or bladder, don’t put off a visit to your doc—schedule is as soon as you can. In these situations, you might need more evaluation, which might include X-rays, MRIs or local injections to help reduce swelling around your nerves if they are determined to be the culprits.

And if you are going to utilize yoga as a healing tool, look for the most qualified and experience teacher around to work with. Later this week I will share the experiences of a good friend and colleague of mine who had sciatica arise during a retreat a few years back and the almost miraculous technique he learned to eliminate this symptom.

Featured Sequence: Low Back Care

by Baxter

Several weeks ago, I introduced some thoughts on low back pain and yoga (see here). As I mentioned, the majority of episodes of lower back pain are related to short-term issues of muscle strain or spasm, or other soft tissue and joint situations that usually resolve in six weeks or so. However, it is possible that a regular yoga practice or a special sequence directed at the lower back area can speed up that process and get you back on track a bit sooner. I have frequently observed that for students who come to class for the first time, acute low back strain often requires only a few sessions in my Back Care Yoga class before the student is well enough to return to or advance to a regular yoga class. In this setting, the variety of poses that may be helpful is a bit larger than with more serious lower back injuries or conditions. For example, you can be a bit more comfortable with some twisting and forward bending poses, which often have to be modified in the other situation.

This week I would like to give you a very brief sequence of poses to consider when addressing low back pain. (The poses in the sequence are all poses that we have already featured individually on the blog.) My intention is to add to this basic sequence over time. However, I have found that it is better to start with shorter practices and advance things as you are ready. Some of the poses in this sequence can be done dynamically, with you moving in and out of the pose with your breath, while others are done more statically, with you holding the pose for 30-60 seconds in most cases.

1. Reclined Hip Stretch Sequence (Dynamic). See here for a complete description of pose. 

2. Reclined Leg Stretch Sequence (Static). See here for a complete description of the pose.

3. Hunting Dog Pose (Static). See here for a complete description of the pose.

4. Half Dog at the Wall (Static). See here for a complete description of the pose.

5. Locust pose (Dynamic). See here for a complete description of the pose.

6. Knee to Chest pose (Dynamic). See here for a complete description of the pose.

7. Corpse Pose (Savasana) with Blanket Roll Behind your Knees (Static).

Notice how you feel after the practice and how you feel the next day. We’ll eventually add more poses to our back care routine, but these are a good start for you.

A Pair of Serendipities Re: Spinal Stenosis

by Baxter

One fortunate thing about teaching a lot of yoga is that students are always coming up and asking me about interesting things that are happening with their bodies. And now our readers here at Yoga for Healthy Aging are also chiming in with intriguing questions about themselves and their students. (Thanks, by the way. We were hoping you would do just that!) Just last week, one such reader wrote in asking about a student with a condition called spinal stenosis. Then on Sunday, the final day of a three-day workshop I was leading in Billings, Montana (burrrrr…24 degrees), one of the students asked about his unusual back pain symptoms. On the list of possible causes that came to mind as he related his symptoms was spinal stenosis. With that, I decided to address this topic on our blog, as it is often, but not exclusively, a result of aging changes around the spinal column.

The condition is one that usually affects the lower back region of the spine, but can also be seen in the cervical or neck area as well. Backing up for a moment to relate some basic anatomy, the vertebral column or spinal column, your backbone, not only essential to our upright posture, but houses within it the spinal cord, or the extension of the brain that connects to the rest of our body. It descends down from the brain via the central canal all the way down to our sacrum bone. As it descends, it sends off nerves at every level of the bony spine to the right and left through small lateral openings called intervertebral foramen.

The Spinal Column

 According to the Cleveland Clinic, with age the spinal canal can narrow, resulting in spinal stenosis. The narrowing process, which is gradual, reduces the space available for the spinal cord and nerves. If only a small amount of spinal narrowing occurs, no pain will result. However, if narrowing continues, the nerves that travel through the spinal column to the legs become squeezed, leading to back and leg pain, numbness and leg weakness. And the pain and other symptoms are more pronounced with standing and walking, and often improved when sitting or lying down. So what does this have to do with aging?  Well, spinal stenosis occurs when bulging discs, arthritic spurs, and thickened tissues combine to "compress" the nerves traveling through the spinal canal or try to exit through the side openings, all of which are more likely to occur as we age. It typically occurs among older adults, and arthritis and injuries can also cause the spinal cord to narrow. I should note that there are also cases in which the condition can arise in much younger adults, but that is another discussion.

And short of strong pain medications and anti-inflammatory drugs, traditional physical therapy, and lastly, invasive surgery, what’s a person to do? Well, thanks to the use of yoga for a variety of back pain syndromes in several studies in the recent past, yoga is now recommended by the American College of Physicians and the American Pain Society as an alternative or complementary treatment.

That’s all well and good, but there are a lot of yoga styles and poses, and if you are already in pain from spinal stenosis, you might be just a bit hesitant to head off to your local gym or public yoga class. And, rightly so. It would better serve you to look for a specialty class that deals with back pain, or better yet, find a qualified instructor or yoga therapist who you could do some private sessions with you to determine which asana and styles of practice would serve you best. Two styles of yoga that have a stronger attention to good healthy alignment of the spine and body are Iyengar and Anusara yoga. Viniyoga or the yoga of Krishnamacharya are also therapeutically focused and designed to work one on one for your unique needs.

With that in mind, there are several recommendations I can make. If a particular group of poses worsen your symptoms, avoid them. If they improve or are neutral in effect, proceed with awareness as you do them. Because back bending tends to narrow the central canal, doing backbends when you have spinal stenosis is usually not recommended, but small amounts of back bending might be tolerated. The opposite movement, however, can often open the canal, so forward bends can be quite beneficial. And if the lateral openings are the issue, lateral side bends and twist away from the side of involvement can also be helpful.  Any poses that encourage a long, balanced spine and optimal posture are also worth practicing, such as Mountain pose, Staff pose, Downward Dog, and so on. And because reclining is often the position of relief for spinal stenosis, Legs Up the Wall pose and Savasana (Corpse pose) would likely end up as favorites.  Restorative practices and yoga nidra are also helpful, as they have the added benefit of calming the nervous system, which is usually on high alert in chronic pain conditions such as spinal stenosis.

Thanks to my students and you readers for today’s topic!