Yoga Is Just As Safe As Other Exercise

by Nina

Sally Halbett by Melina Meza

It turns out that Baxter, Timothy, Brad, and I weren’t the only ones who were seriously skeptical about the claims that New York Times writer William Broad made about the dangers of yoga (suspiciously timed with the releases first of the hardback and then of the paperback versions of his book about yoga). I’ve just learned from Yoga Is Just As Safe As Other Exercise, Study Finds that Dr. Holger Cramer, director of yoga research at the University of Duisburg-Essen in Germany, read Broad’s article “How Yoga Can Wreck Your Body,” and concluded that it “reported on some cases, but it was not systematical.” And since no meta-analysis—a systematic review of other studies—yet existed on yoga injuries, Cramer decided to do one himself. Thank you, Dr. Cramer!

And guess what? Dr. Cramer’s completed study The Safety of Yoga: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, published in the American Journal of Epidemiology, found that yoga was just as safe as other forms of exercise.

“No differences in the frequency of intervention-related, nonserious, or serious adverse events and of dropouts due to adverse events were found when comparing yoga with usual care or exercise.”

Yes, that’s basically what we’ve been saying all along (see Man Bites Downward-Facing Dog, Is Yoga Really Dangerous for Men?, and Is Women's Flexibility a Liability in Yoga?, among other posts responding to William Broad's claims). No, yoga is not perfect. And, yes, you can injure yourself while doing it, so it’s wise to use common sense when you are taking a class or you’re practicing on your own (see How to Stay Safe While Practicing Yoga). But you can also get injured running, walking, playing tennis, biking, lifting weights, gardening, etc. And even being sedentary has its dangers. How many people do we know who got injured just sitting at their desks or developed serious health conditions due to lack of exercise?

We’re pretty sure that Broad didn’t do a methodical study of any kind (he’s a journalist, not a scientist). On the other hand, according to Yoga Is Just As Safe As Other Exercise, Study Finds, Dr. Cramer looked only at randomized controlled trials—considered the highest quality clinical trial.

“Studies qualified if they compared any kind of yoga with no treatment, usual care or an active treatment, and if they reported on adverse events like injuries. In the end, 94 studies—which looked at a total of 8,430 people—made the cut.

Only 2% of people who did yoga experienced any adverse events, and some of those who did already had severe diseases. The study didn’t look at the types of injuries, but other data suggests that the most common kinds of injuries are musculoskeletal, like back pain, Cramer says. Other adverse events include aggravation of glaucoma in patients with the disease, especially in headstand or shoulder stand poses.”

No surprises there. We know that people can get musculoskeletal injuries from pushing themselves too hard in a pose or from practicing the same poses over and over (see Not All Yoga Poses Are Created Equal and Getting Clearer on Yoga and the Risk of Injury). And we always caution people with glaucoma and certain other conditions about practicing inversions like Headstand and Shoulderstand (see Friday Q&A: Cautions for Inversions). But Dr. Cramer also confirmed what we’ve observed—both about ourselves and our students—that while serious yoga injuries are rare, benefits from the practice are much more common:

“We have really high-quality studies showing that yoga is effective for chronic low back pain in the short and long term,” he says. Other good evidence shows that yoga can ease depression and psychological distress in breast cancer patients, he says, and that yoga may be effective in lowering high blood pressure in people with hypertension and reducing cardiovascular disease risk factors in the general population and people at high risk.”

When I told Brad about this new study and its conclusions, he simply said, “No sh*t.”

Happy practicing!

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Differences Between Male and Female Pelvic Structures

by Shari

This is the second part of my response to William Broad’s assertion that women—because of their inherent flexibility—are more apt to injure their hips in a “dangerous” yoga class or perhaps during a home practice. I think it is important to understand that whether or not women are more inherently flexible than men, there are significant physiological and anatomical differences in the male and the female pelvis. Have a look at these two pictures!

Female Pelvis

Male Pelvis

As you can see here, the female pelvis is typically larger and broader than the male pelvis, which is taller narrower, more compact and stable. The female pelvis is thinner and it is more mobile partly due to hormonal changes that a woman cycles through and partly due to inherent structural attributes. There is also a difference in the size of the pelvic outlet specifically due to the reproduction capacity of the female The weight-bearing surfaces of the pelvis are larger and more irregular in the male, whereas the female pelvic joint surfaces are smaller and flatter. This structural difference is specifically important in how the sacroiliac joints “lock down” to form a stable weight bearing arch linking the legs with the torso.

The way weight is transmitted through the pelvis is different with the male pelvis having a more vertical weight-bearing loading and the female having a more posterior weight-bearing load. Of interest, male pelvises are often fused after the age of 50 in 50% of males whereas only less than 1% of women’s are fused at or after the age of 50.

The acetabula are wider apart in females than in males. In males, the acetabulum faces more laterally, while it faces more anteriorly in females. Consequently, when men walk the legs can move forwards and backwards in a single plane. In women, the legs must swing forward and inward, from where the pivoting head of the femur moves the leg back in another plane. This change in the angle of the femoral head gives the female gait its characteristic swinging of hips.

So if we really want to be anatomically correct, it becomes obvious that women need to do their standing poses differently than men specifically because of our anatomical differences in our structure. In particular, it is wise to leave room for your hips in your standing poses by changing your stance. In poses such as Triangle pose, Extended Side Angle pose, Warrior 1, 2, and 3, Revolved Triangle pose, Pyramid pose (Parsvottanasana), instead of aligning your feet as we are typically instructed to (with your front heel aligned with your back arch), try widening your stance a bit by aligning your front heel with your back heel. Otherwise, if your base of support is too narrow side to side, a lot of accommodations will occur with torqueing and twisting of various body parts that could lead to injury over time.

In addition, these differences in our morphology are important because this—not just inherent flexibility as William Broad claimed—may possibly lead to more injuries for women and therefore they need to be especially careful. A post from me on Healthy Hips, which applies both to women and men, will be coming soon.

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Friday Q&A: Is Women's Flexibility a Liability in Yoga? Baxter's Response to William Broad

The Flexible Melina Meza!

Q: So, Baxter, what do you think of William Broad’s latest claim that women’s flexibility is a liability in yoga?

A: Firstly, I want to thank Shari for her level-headed look at New York Times science writer and author of The Science of Yoga William Broad’s most recent assertion that women who do yoga are at great risk of injury due to their flexibility (see Women's Flexibility is a Liability in Yoga).  Thanks, as always, Shari, for your practical experience as a physical therapist and a long-time yoga practitioner and yoga teacher. I think your insights will go a long way in helping clarify articles like these that may have an unstated agenda that colors and lessens their credibility. I’d also direct some of you to this balanced response by yoga teacher Paul Grilley to the article as well. As always, William Broad’s articles do get us thinking and talking about yoga. 

But if I read Broad’s most recent article and his latest assault on yoga accurately, am I to understand correctly that both men’s tightness and women’s flexibility are liabilities in yoga? So is yoga now safe only for animals and children? I have always encouraged men to try yoga because they seem to hold so much tightness in their bodies. And women often master the more challenging poses in yoga from a seemingly more inherent flexibility. But I also have plenty of incredibly flexible male students and an equally large number of stiff and inflexible women in my classes. 

As a yoga teacher and also a student of yoga for several decades, I find most teachers today are cautionary to their students to be mindful of the feedback their bodies give them as they approach more physically challenging yoga poses. And yet, as if to throw one more barb of accusation at yoga and its teachers, the author offers this final warning: Unfortunately, yoga teachers too often encourage students to “push through the pain.” 

With all the supposed statistics the writer offers in the article, none are offered with this statement, and I am not certain where this impression comes from. I know that this can happen in some classes and styles of yoga, but this generalization, I believe, does not represent the overall state of yoga teaching in the US today.

And the tone used by the author implies that he has uncovered some hidden or unknown risk to yoga practitioners, and, more pointedly, women, that some of them could be at risk of hip injuries or impingements. As far back as 2009, the International Journal of Yoga Therapy published an article by Elaine Goodall "Preventing and Healing Injuries in Yoga: Acetabular Labral Tears.” In her detailed article, Ms. Goodall notes that gymnasts and dancers may have a predisposition for these kinds of injuries as well as some in yoga. So much for breaking news! 

One of my difficulties with the statistics—if they can be called statistics—that are offered in the New York Times article to back up the assertion that women are at a significant risk of hip injuries of a very specific kind is statements like this:

“Each year, he (Dr. Kelly) said, roughly 50 to 75 of his patients who danced or did yoga underwent operations. Most, he noted, were women.” 

The author goes to the effort of interviewing a surgeon, getting a guesstimate from said doctor, and never follows up with: how many were yoga related and how many dance related, and how many were a combination (as many yoga students, men and women, danced when younger)? And how many were men? What meaningful conclusions can a yoga teacher make from such superficial exploration?

In addition, the author points to a 2008 study done in Switzerland that looks at the kind of unique arthritis/traumatic changes to the hip called Femoral Acetabular Impingement, or FAI. However, he fails to mention that the women in that study had unusual hip anatomy, considered abnormal, though subtly so. The authors of the study go on to say, “The focus of the new concept (the theory on what underlies FAI) addressed those remaining cases of hip OA (osteoarthritis) in which the deformity (FAI) was considered mild, slight or even, in the eyes of casual observers, nonexistent.” 

So women and men who develop this impingement injury to the hip (prior to starting yoga) already had an anatomical reason that movements in the hip joint could lead to injury. Interesting. Developmental abnormalities that usually arose prior to adulthood were present in most cases. And this kind of FAI occurs in men and women, not women alone. Only once does this study mention that the pincer-type of injury is to women with underlying anatomically abnormal hips. And that these women often participate in “yoga and aerobics.” The authors don’t say the yoga caused the problem. As Paul Grilley so astutely points out, correlation does not mean causation! In fact, yoga is never mentioned again in the fairly lengthy article, and not at all in the final wrap up discussion that usually highlights the facts they find most compelling. They also don’t give statistics that clearly outline what percentage of women, with hip pain that requires surgery, have this kind of injury (FAI). So, again, the practical applicability for us in-the-trenches teachers is very unclear.

And statements like this are just mystifying: “I found that hundreds of orthopedic surgeons in the Mediterranean region heard a conference presentation in 2010 that linked F.A.I. to middle-aged women who do yoga.” If this was true, why does he not cite the study or the “presentation”? What was the presentation based on? Who made the presentation? Was there any study to back up these assertions?

And quotes like this: “Michael J. Taunton, an orthopedic surgeon at the Mayo Clinic, told me that he first learned of the danger a half decade ago and now annually performs 10 to 15 hip replacements on people who do yoga. About 90 percent, he added, are women.” This again does not help me much, as I don’t know how many hip surgeries this doctor does each year (about 20-30 a month, I would guess), so this may represent a small percentage of his annual surgeries, but the way it is presented seems really worrisome, if not epidemic, if you don’t have all the facts.

I have been teaching about the risks and benefits of yoga to future yoga teachers now for over 10 years. Some sort of classroom instruction on the topic is included in many 200-hour beginning level teacher trainings. So, from my personal experience and perspective, the yoga community is aware of potential dangers of certain aspects of the physical practices of asana and is better defining and sharing that information with each passing day.

Despite the author’s initial statements on the wonderful potentials of yoga in the first paragraph, little that follows in his article supports this assertion. I reminded myself that the final chapter of The Science of Yoga does give some insight into the author’s feelings and motivations regarding yoga:

“Yoga can grow up or remain an infant—a dangerous infant with a thing for handguns.” 

And a bit later in the epilogue, when discussing his concerns for the commercialization of yoga, he seems to pushing for huge government oversight of yoga with the following:

“Imagine if Big Pharma had no Food and Drug Administration and other regulatory agencies looking over its shoulder. The marketing of fake diseases and bogus cures…would be much worse.” 

And in the time since the release of his book, the three articles Mr. Broad has published have only dealt with potential negative aspects of yoga: the two on the dangers of yoga to men and women and one on the sexual scandals of yoga teachers.

How about a story from this self described yoga practitioner on the benefits of yoga next next time instead of sensationalist fearmongering?

—Baxter

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Is Women's Flexibility a Liability in Yoga? Shari's Response to William Broad

by Shari

The latest New York Times article from William Broad Women’s Flexibility is a Liability (in Yoga) sparked a conversation between Nina and me, both whom are long-term yoga practitioners who have grappled with orthopedic injuries. Broad states that he has recently learned that women are at higher risk of hip injuries in a yoga class because of their inherent flexibility compared to men. He quotes a single yoga teacher, Michaelle Edwards, saying that “women’s elasticity became a liability when extreme bends resulted in serious wear and tear on their hips. Over time the chronic stress could develop into agonizing pain and, in some cases, the need for urgent hip repairs.” He also says of arthritis researchers:

The investigators found that extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis. They called it Femoroacetabular Impingement — or F.A.I., in medical shorthand. The name spoke to a recurrence in which the neck of the thigh bone (the femur) swung so close to the hip socket (the acetabulum) that it repeatedly struck the socket’s protruding rim.

I personally can’t stand sensationalism of any type and particularly sensationalism of the fear and scare tactics kind. When I first saw this article, I groaned inwardly. But I then proceeded to read it carefully, including the related links, and then went on to do some additional research of my own. After all that, my response is: maybe.

First of all, I, as a long-term yoga practitioner, am not sure what exactly he means. We all can be overly flexible in some areas of our bodies and conversely overly tight in other areas of our bodies. The biomechanical model of structure and function is a beautiful yin and yang interplay between forces that influence our bodies, and yes, can ultimately change our structure and function. Some changes may not be as beneficial as others so we need to be consciously selective and astute to observe what changes occur with function.

I also think, as in the past, Broad is careless in his citations of his evidence and is vague about these ER records of hip injuries. However, he does cite some orthopedists and one international study that do substantiate his observation that women who put their hips into extreme ranges of motion can injure their hips. Well, this is blatantly obvious to anyone who may be neurologically intact. When a joint is taken into an extreme position there is a pain response recognized by the central nervous system that warns the person to back off. Of course, if we choose to ignore the pain response, then is it the yoga that is causing the injury or is it the person who is foolishly not listening to the feedback their body is providing?

I also think that to address William Broad’s assertion that women are more flexible than men, we need a better working definition of (biomechanical) flexibility:

Flexibility is the range of motion in a joint or group of joints, or, the ability to move joints effectively. Flexibility is related to muscle strength. Flexibility is also the ability to move through a full range of motion.

Flexibility is a conscious movement that has an intricate feedback mechanism between the muscles and the nerves innervating the muscles and the joints and the central nervous system. There are significant protective mechanisms that prevent the individual from overstretching if they PAY ATTENTION to the sensation of pain rather than ignoring it.

So are women “inherently” more flexible than men? Well, it depends who you ask. But all sports attract a body type, and if yoga is considered a “sport” then there is a body type that is drawn to yoga. We all like to do things that are “easy” and for some flexible bodies yoga is “easy.” The rub here is that this isn’t “yoga” but athleticism masquerading as yoga!

So now let us look at his assertion that yoga is the root cause of “femoracetabular impingement”. The literature that I read, including one of his references, states that the subjective symptoms are deep anterior groin pain with associated intermittent catching and locking of the hip joint. In addition, there is a significant decrease in hip internal rotation. The morphology is that there is a breakdown of the hip labrum (how the head of the femur is connected into the cup of the pelvic acetabulum) and the articular surfaces of the femur and acetabulum. There is a structural change in how the head of the femur is sitting and facing, and movement of the hip will continue to tear the tissue structures with a loosening of the integrity of the hip joint. The problem is that a lot of individuals who have this condition are pain free, asymptomatic and don’t know they have it. The concern is that this condition may be a precursor to developing hip arthritis down the road. There are four types of femoracetabular impingement and one type is more common in women and one type more common in men!

Another article that I read stated that the condition is caused by internal rotation of the hip while in 90 degrees of hip flexion. Yes, this can be Uttanasana (Standing Forward Bend)! So is the problem the combination of these two movements? I don’t know, but does that mean you need to stop doing Uttanasana? I don’t think so unless it is causing pain. And, yes, there are some pretty extreme hip positions in yoga which only some of could do when we were younger (maybe can still do them now) but the bottom line is that we need to practice with intention and attention to form, function and our own bodies' abilities and not soldier on through the pain. Yoga, as we have mentioned time and time again, can be physically and mentally challenging, but is not supposed to hurt. So don’t be scared off again by a sensational journalist who claims he is a yogi.

In a future post I would like to present some of the inherent differences between male and female pelvis and hips that might also help to put into perspective the allegation of the differences between men and women.

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Man Bites Downward-Facing Dog: Dr. Timothy McCall Takes On William Broad of The New York Times

by Nina

Mugsy, the Yoga Dog by Nina Zolotow

Could yoga make you fat (especially if you're a woman)? Does it cause hundreds of strokes per year? Sex you up so much you'll engage in unethical behavior? Did the entire discipline start out as a sex cult? If you read The New York Times you might think so. As much as I've often disagreed with him, up until now I've been diplomatic in my responses to William Broad's writings about yoga in Times and in his book The Science of Yoga. But after his recent article in which he asserted that "yoga is remarkably dangerous — for men," I felt it was time to speak up. —Dr. Timothy McCall

In his new paper “Man Bites Downward-Facing Dog,” Yoga for Healthy Aging blogger and Medical Editor for Yoga Journal Magazine, Dr. Timothy McCall responds to William Broad’s ongoing sensationalistic claims about yoga. In his post on our blog Is Yoga Really Dangerous for Men?, Timothy addressed Broad’s most recent claim that yoga is “remarkably dangerous” for men. In this new paper, he goes further and responds to other over the top claims that Broad has made previously, such as that yoga can make you fat or that the entire discipline started out as a sex cult. He also makes it clear that he is not denying that yoga injuries are a problem; and he acknowledges that he is not in disagreement with all of William Broad's assertions.

Timothy's article is on his web site, in  PDF format rather than on a web page. So if you want to read it, you’ll need to download it and view it with Adobe Acrobat. To get your copy of the paper, you can either use the link in the previous paragraph or go to Timothy's web site www.drmccall.com. I highly recommend that you go ahead and download the paper. Then feel free to pass it on to your friends. We really want to get the word out!

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Is Yoga Really Dangerous for Men? Dr. Timothy McCall's Response to William Broad

by Timothy

Science reporter William Broad, who a year ago woke the proverbial sleeping (downward facing) dog of the yoga world with his NY Times Magazine article How Yoga Can Wreck Your Body, is back at it. This time he's claiming—based on a review of injury statistics—that men are at much greater risk of serious injury from yoga (see Wounded Warrior Pose). The claim may or may not be true, but I don’t think you can really tell from the data he presents. I plan on writing more about this topic in my next email newsletter, but wanted to respond to Nina's query for the blog today.

Man in Unwounded Warrior 3 Pose by Nina Zolotow

As Broad makes clear in his book, The Science of Yoga (from which the first Times yoga article was excerpted), the subject of his inquiry is the physical practice of yoga as found in most classes. He’s not talking about meditation, chanting, selfless service or spiritual development. Even so, styles of asana practice, different teachers and classes vary enormously. It’s my feeling that Broad's failure to account for these differences could entirely explain his findings.

Back when I was taking a lot of classes of different styles (which I'm not doing anymore, so if things have changed I’d love to get feedback from readers), I found that in the more meditative and restorative classes, I was often one of the only males in the room. But in some of the more vigorous and acrobatic classes, the gender split was closer to even. Thus, men having a higher incidence of yoga injuries could simply be a reflection of their favoring the kinds of classes where injuries seem more common, and not actually reflect any greater vulnerability to injury.

It is also my experience (and that of most yoga teachers I’ve spoken with) that people who are more flexible are generally at greater risk of injury, particularly for injuries like hamstring muscle tears, and overstretching of the ligaments. It varies from person to person obviously, but on average men are much stiffer than women, and seemingly less prone to these types of injuries.

Many yoga injuries—again based on my experience, since we lack data—happen when people are trying too hard to achieve a particular result. Your foot won’t go into Lotus pose, for example, so you pull a little harder to get it into position, and in the process tear ligaments in your knee. But before that happens, the body almost always gives warning signs, such as pain or strained breathing. If you decide to ignore them and power your way through, problems may result. Both men and women can do this, but if I had to guess I’d say men are more likely to, so in this way may be at higher risk.

William Broad loves to create controversy. Beyond claiming that yoga can wreck your body, he has also written that yoga can make you fat, and that the entire practice started out as a sex cult (neither of which is true). Statistically speaking, if Broad’s analysis is correct (and given the methodological problems in how he did his analysis—see Is Yoga Really Dangerous for Men? Dr. Ram Rao Weighs In—I don't think we can know), men may indeed be at higher risk of injuries when practicing asana, but this may miss a larger truth. My guess is that if a man practices less demanding forms of yoga, or any style of yoga in a less aggressive and more mindful way, that his risk probably isn’t any greater than that of a woman, and may even be less. Uh oh, there’s a potential future headline for Mr. Broad: Women at Greater Risk of Yoga Injuries! You heard it here first….

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Is Yoga Really Dangerous for Men? Dr. Ram Rao Weighs In

by Ram

Recently William Broad, author of The Science of Yoga, wrote an article in the New York Times Wounded Warrior Pose, which claimed that yoga is “remarkably dangerous” for men. While this article is a must read for folks who practice yoga asanas (practitioners, teachers in training or students), there are several important issues mentioned in the article that needs to be properly understood and clarified.

Happy, Healthy Warrior Pose

Let’s start by clarifying for the benefit of practitioners and non-practitioners: the main reference throughout the article is to yoga asanas and not yoga per se. While this seem trivial, it is very important because one can resort to other yoga activities like dharana (focus), dhyana (meditation), pranayama (regulated breathing) and sustain very minimal if no injuries. Also, yoga is not a competitive sport; for more on this kindly refer to BKS Iyengar’s book Light on Yoga.

While it may seem that the practice of yoga asana is largely a feminine pursuit, such gender inequalities exist in several other sports and training programs. We do not see a mainstream ladies equivalent of American football, the zumba and pilates classes in the gym that I go to is dominated by females and it is mostly men that are busy working out their “ceps and packs” in the weight lift arena. Uncoordinated or improper movements can put an individual at risk and subsequent injury in any sport or training program. The same is true for yoga asanas, which require coordinated movements of several areas/parts of the body.

William Broad acquired medical data, performed a non-scientific partial analysis and concluded that gender differences in yoga injuries exist and men are at most risk for these types of injuries. To me it seems that the differences could be explained at least in part by differences in the amount of training and asana practice.

Retrospective training/sport injury studies have to be normalized (a suitable denominator has to be factored in). Typically, total exposure time in hours or months or years have to be factored in to draw a reasonable conclusion. In a retrospective 12-month scientific study reported by a group in Finland and published in the 2009 issue of Journal of Sports Science and Medicine, the authors concluded that after combining all reported acute injuries sustained by cross-country skiers, swimmers, long-distance runners and soccer players, no significant difference was observed in such injuries when calculated per 1000 exposure hours.

Similarly, another study comparing sports injuries in men and women that was reported by a group of family practitioners from Kaiser Permanente found no statistically significant gender difference for injuries per 100 participant-years (Sallis et al; Int J Sports Med. 2001 Aug;22(6):420-3. Comparing sports injuries in men and women).

If proper scientific standards were applied to Broad’s yoga analysis, it would mean factoring in the mean exposure hours of yoga asanas performed. Based on the above studies my gut feeling is that no gender differences would similarly be found in injuries sustained from yoga asanas.

So do not be put off by Broad’s article! Remember yoga philosophy, which includes asana practice as well, does not discriminate between estrogen and testosterone. The major component of the practice is about “letting go” of the ego, including your body image, and finding your true self. So focus on yourself and your personal practice. And focus less on a “macho” body and more on achieving stability, mobility and encouraging integration—gently coaxing all the muscles that are tight from sports and weight training to move and work together. Pay close attention to connections—between one part of the body and another, between thought and action and between breath and movement. Moving with this awareness helps in reducing risks from any serious injuries.

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