The Science of Yoga: The Risks and the Rewards (24 page)

Extended hand to Big toe,
Utthita Padangusthasana

One glossy feature in
Yoga Journal
devoted ten pages of colorful photos and prickly text to the risks. “Yogi beware: Hidden dangers can lurk within even the most familiar pose,” read the headline. Judith Lasater, a physical therapist and president of the California Yoga Teachers Association, argued that most poses hold subtle menace. The inherent risks can become quite palpable, she wrote, “because you may not have the necessary knowledge, flexibility, strength, and subtle awareness to proceed safely.”

On another occasion, Kaitlin Quistgaard, the editor of
Yoga Journal
, told of how she had reinjured a torn rotator cuff in a yoga class, her pain becoming a cruel presence for months. “I’ve experienced how yoga can heal,” she wrote. “But I’ve also experienced how yoga can hurt—and I’ve heard the same from plenty of other yogis.”

And, no doubt, from plenty of lawyers. In fine print, the magazine began to run a legal proviso: “The creators, producers, participants, and distributors of
Yoga Journal
disclaim any liability for loss or injury in connection with the exercises shown or the instruction and advice expressed herein.”

To its credit, the
magazine paid attention to strokes, although it did so somewhat defensively and superficially. “Proceed with Caution,” read the headline of its one-page article. The large color photo showed students upended in Headstands. The neck of a woman in the foreground was backlit and stood out. The article said doctors had identified five risky poses: the Headstand, the Shoulder Stand, the Side Angle pose (which Krishnamacharya had hailed as a cure), the Triangle (which Iyengar had carefully aligned), and the Plow, or Halasana. It had students lie on their backs, lift their legs up over their heads and back down onto the floor, inverting the torso. The article said such poses were judged potentially dangerous because they “put extreme pressure on the neck” or resulted in “sudden neck movements.”

Plow,
Halasana

It said nothing of two other poses that physicians had identified as serious threats to the brain: the Cobra and the Wheel, both considered X-rated postures.

The article warned that
yoga practitioners could mistake injuries of the vertebral arteries for simple migraines or muscle tension. The symptoms of deeper trouble, it said, included piercing neck pain, pounding one-sided headaches, and facial paralysis. “Warning signs,” it cautioned, “can intensify for hours or even days before a stroke hits.”

So far, so good. But the magazine then proceeded to downplay the threat by failing to put the issue in perspective. It said doctors had found injuries to the vertebral arteries from all causes (such as yoga, beauty salons, and chiropractors) to be rare—annually, a person and a half out of every hundred thousand.

This was accurate. But it ignored the big picture. If twenty million people in the United States did yoga—a standard figure—and if yogis suffered the injury at the same rate as the general population (a very cautious assumption, given all the neck twisting and bending), that meant three hundred yogis in the United States faced the threat of stroke each year, or three thousand over a decade. The magazine not only neglected that baseline figure but sought to put its readers at ease by stating that yoga was “the culprit in a minuscule number of cases.”

The reassurance was empty because the medical world had exactly zero evidence about the frequency of such damage. In fact, no scientist had ever published a study on how often yogis injured their vertebral arteries. The question was far too esoteric to have received the kind of major funding that would be required to address a deep riddle of epidemiology. So the exact size of the problem with yogis in the United States was simply unknown. What was easy to estimate was its minimal extent—roughly three hundred yogis a year.

Seeking to further brighten the grim subject, the magazine said “treatment is simple” and called rates of recovery high. But that rosy prognosis required that it ignore the agonizing months and years of therapy, the hand tremors and the clumsy gaits, the patients whose arms continued to waver and eyelids continued to droop.

Then, in what was apparently meant to be more good news, it added: “Death results in less than 5 percent of the cases.”

Here again, the figure was correct but misleading because it failed to put the number in perspective. If three hundred yogis in the United States suffered injuries of the vertebral arteries each year (the lowball estimate), 5 percent of that would be fifteen—fifteen yogis who lay dead after wounds to their vertebral
arteries resulted in brain injuries serious enough to kill. And the real number of fatalities, despite the percentage being “less than” five, was probably higher given the large number of poses in yoga that involve extreme contortions of the neck. Maybe it was thirty fatalities annually, and maybe three hundred over a decade. Globally, the fatalities might number in the thousands. It was an open question.

The article ended with a list of cautions—listen to your body, move slowly, avoid thrusting or jerky motions, go up to the point of resistance but never beyond. Its last warning focused on the neck. It advised students, especially beginners, to avoid putting the relatively thin, upper part of the spine in a position where it had to support a lot of body weight.

The magazine’s attempt to deal with the sensitive topic appears to have made few waves in the world of yoga practitioners. Outside of
Yoga Journal
, the article got no general notice on the Internet from blogs, studios, or magazines, unlike the magazine’s aerobics news. It rapidly sank into the void of cultural forgetfulness.

The subject of stroke nonetheless proved to be a topic of continuing worry among yogis—even if the discussions were superficial. More than three decades after Russell’s warning, after the clinical reports, after the crystallization of medical concern, after the debut of the X-rated exercises, and after the threat summary in
Yoga Journal
, practitioners could still get lost in a cloud of uncertainty.

In 2004, the Internet buzzed with discussion about a woman of thirty-nine who did Power Yoga nearly every day and had suffered two strokes that threw her into the hospital. Her doctors, a friend reported, called her yoga routine the apparent cause and advised her to drop the practice. The woman did a beautiful Shoulder Stand, her friend reported in a discussion forum. But she wondered if the identified source of the trouble could possibly be accurate.

“Misinformed and misguided,” one discussant said of the attending physicians. “Blaming yoga for a stroke is absurd.”

During this period, yoga in America felt the sting of bureaucratic oversight for the first time as states began to regulate the training of teachers. They did so under the banner of consumer protection, the effort expanding in step with the new disclosures and the rising debate.

Regulators said licensing the schools would let states enforce basic standards and protect customers
who typically spend thousands of dollars on training courses, as well as improving the quality of the experience for their students. “If you’re going to start a school,” said Patrick Sweeney, a Wisconsin licensing official, “you should play by a set of rules.”

A disturbing new kind of injury came to light even as states began their regulatory effort. The case involved a woman of twenty-nine who was undergoing teacher training at Kripalu, the yoga emporium in the Berkshires. One night, she was practicing the rapid breathing method known as Kapalbhati Pranayama, or Shining Skull Breath—the form of Breath of Fire that Bikram students do as a grand finale. The next day the woman awoke with shortness of breath and pain in her left chest. Her symptoms slowly worsened, and she was taken to the Berkshire Medical Center, just up the road from Kripalu in Pittsfield, Massachusetts.

The doctors in the emergency room, upon seeing the woman’s labored breathing and learning of her troubles, quickly put her on oxygen. The urgent question was what had gone wrong.

Lungs are like sponges that soak up air. They are highly elastic but largely passive. During a breath, the chest wall expands, forcing the sponge to draw in air. During exhalation, the sponge contracts and air goes out. It is mainly the action of the chest wall that governs the rhythms of the respiratory cycle. The sponge can do little on its own without the application of external force.

A quick X-ray showed that the woman was suffering from a serious failure of this mechanism, known as pneumothorax (from the Greek words for “air” and “chest”). The condition arises when air leaks into the space between the lung and the chest wall, loosening the usual grip of the wall and letting the sponge collapse. The lack of movement and breath can be life-threatening, especially if it involves both lungs. In the woman’s case, the pneumothorax had partly collapsed her left lung.

In an emergency procedure, the doctors administered a local anesthetic, cut a hole between her ribs, and inserted a small tube that penetrated her chest wall and entered the pleural space. Then they extracted the unwanted air, allowing the chest wall to come back into play and her lung to reinflate. Immediately, the symptoms of labored breathing went away. The woman, after a week of recovery, underwent a procedure for removal of the tube.

In 2004, the doctors
from the Berkshire Medical Center documented the unusual case in
Chest
, the respected journal of the American College of Chest Physicians. They noted that an imaging scan of the woman’s chest had revealed no lung pathologies that might account for the pneumothorax, and concluded that the rupture was a direct result of yoga breathing. The case was without known precedent, they said, and showed that “adverse side effects can occur when one pushes the body to physiologic extremes.”

In this case, the yoga community took notice and reacted. The days of denial and evasion were ending rapidly as the once-secretive topic of yoga injuries increasingly went public.

A yoga teacher and a medical doctor who had advised the teacher in developing a program for people with breathing disorders wrote a joint letter to
Chest.
The two, based in Sacramento, California, agreed that the rapid breathing exercise “most probably induced the pneumothorax” and backed the report’s cautionary advice. But they said its warning about pushing the body to physiologic extremes created a false impression that “appears to unjustly blame all yoga techniques. This is not appropriate for a discipline that has generally been practiced safely for not hundreds, but thousands of years.”

The yoga teacher—Vijai P. Sharma—took to the pages of the
International Journal of Yoga Therapy
to discuss the case and argue for the relative safety of Kapalbhati and other yoga breathing exercises. But his argument was heavy with caveats. He drew a distinction between fast and slow breathing, saying yoga’s quick styles posed greater risk. Fast breathing, he wrote, “may reinforce or worsen preexisting structural or functional problems.” Finally, Sharma enumerated a long list of safety guidelines and heightened risk factors (diabetes, chronic hypertension, persistent head pain) that made fast breathing seem like it was generally a risky venture.

Unless students exercise “out-of-the-ordinary patience and self-control,” Sharma warned, “rapid breathing techniques such as Kapalbhati and Bhastrika are likely to be performed incorrectly and prove harmful in the long run.”

Yet another case that came to light featured an aging yogi. The man had done yoga since his thirties and was sixty-three when the trouble hit. His daily practice included
the Headstand. He suffered no neck or back problems until one day he began to feel tingling and numbness in his fingers and toes. Over a few months, his legs and arms grew increasingly weak, and he began to experience the urge to urinate frequently.

His doctors saw the symptoms as classics of quadriplegia—limb weakness due to an injured spinal cord. Diagnostic imaging showed a region of disk compression and displacement between the C3 and C6 vertebrae. Health professionals, they wrote in their 2007 report, “need to be aware of this potentially serious complication of a relatively innocuous exercise.”

In my thirties, I somehow managed to rupture a disk in my lower back. The cause seemed to be the repeated shocks of running on pavement rather than yoga. I looked into surgery, but found I could prevent bouts of pain with a selection of yoga postures and abdominal exercises.

In 2007, I experienced my own “serious complication” while studying with Robin in Pennsylvania. It happened as I did the Extended Side Angle pose, or Utthita Parsvakonasana. That was the posture that Krishnamacharya praised as a cure for many diseases. I was coming out of the pose and chatting with my partner—instead of paying attention to what I was doing—when my back gave way.