Neck Position in Camel Pose (Ustrasana) and Other Backbends

by Baxter and Janet Rae Humphrey

Margann Green, Age 77

We received this excellent set of safety recommendations for Camel pose for older adults from Janet Rae Humphrey, E-RYT, of YogaForStability.com in Scottsdale, Arizona, and wanted to share it with you all: 

Dear Nina and Baxter, 

As a yoga teacher who specializes in older adults ages 70 to 95, I would like to comment on your post Are Backbends Stimulating or Relaxing?

The photograph of Margann Green doing Camel inspires me to write about precautions that are necessary when teaching people over 70. At age 77 Margann’s ability to do a full Camel pose is remarkable and certainly shows the advantages practicing yoga as one ages. I see a distinct difference between the residents of senior living centers who have exercised all their lives and those who have not. The first group is far stronger, more flexible, and is less likely to use assistive devices. Those that begin a yoga practice in their later years also benefit greatly by the increased mobility that yoga offers. 

Camel is frequently performed and photographed with the chin up to the ceiling or the head tilting back even further. In yoga we follow the principle of doing no harm. Camel, therefore, as well as other poses, needs to be modified as we age. 

Baxter identified how aging affects the cardiovascular system in his post The Aging Heart: How Aging Affects the Cardiovascular System:

• Baroreceptors (see Why You Should Love Your Baroreceptors) become less sensitive with aging, which can contribute to sudden drops in blood pressure when you move from reclining to sitting or standing, and general dizziness. 
• The walls of the smallest blood vessels, the capillaries, can get thicker with aging, which could contribute to slower exchange of fuel and waste into and out of our body’s tissues. 
• Both the main artery leaving the left heart, the aorta, and other arteries in the body start to have changes in their connective tissue layers. This can lead to the vessels becoming stiff and less flexible, which in turn can make the heart work harder. 
• Arteriosclerosis, or hardening of the arteries (mentioned in #8 above), in which fatty plaque deposits inside the blood vessels cause them to narrow and which can totally block blood vessels. 
• Transient ischemic attacks or strokes can occur if blood flow to the brain is disrupted, as a result of arteriosclerosis, arrhythmias, and other factors in the CVS. 

These types of changes may affect the ability to do and/or the safety of a person assuming certain physical positions or yoga poses. 

I worked in the neurology department at several teaching hospitals and have seen the damage done by someone over 70 tilting their head back. Think stretching a piece of rubber tubing with fluid running through it. The shape changes from round to flat and the opening is greatly restricted. When the stretching stops, the fluid gushes through with increased pressure. 

When the head is tilted back, the carotid arteries in the neck become flat and the flow of blood to the brain is restricted. This can lead to a stroke or transient ischemic attack. Furthermore, when the head is lifted, blood rushes to the head, increasing the blood pressure. This becomes more problematic with aging because the baroreceptors are less sensitive to changes in blood pressure, the walls of the blood vessels are thicker, fatty deposits in the vessels further restrict the blood flow, and the capillaries in the brain are more likely to burst when they are under high pressure. 

One of the more common places for older women to have a stroke is in the beauty parlor when their hair is being washed. I mentioned this in a class I taught and one of my older students said that was where she had a stroke. 

I encourage your readers who teach people 65 and above to remind students to keep their chins tucked and not allow their head to fall back during back bends. One way to do this is to put one hand behind the head to support the head during a backbend. 

A second reason for older adults not to tilt their head back is the changes in the discs between the vertebrae as we age. Baxter discuss these changes in his post Degenerative Disc Disease and Yoga: 

"Degenerative disc disease is a process of change to the cushion-like discs found between the vertebrae or spinal bones. It most commonly affects the discs in the neck/cervical region and the lumber/lower back region. There is some ongoing debate on whether the deterioration of the discs is a natural part of the aging process (since it is seen in people without symptoms of back or neck pain in gradually increasing percentages as we age) or whether it is directly related to an abnormal condition of change in the discs. It is really part of the general wear and tear arthritic changes we see in other joints, as the discs represent a unique kind of cushion structure that is similar to the cartilage caps found on the ends of other bones in major joints of movement. But it is different from the regular cartilage in other joints in that it is a larger structure, not adherent to the vertebrae above and below it, as well as having a unique structure that distributes the intense force of gravity that travels down the spine in a specialized way. 

Not only do the discs degenerate, but they also lose moisture and become thinner and denser. Their cushioning ability decreases. A sponge fresh from the package is tall, soft and pliable. An old sponge that has been sitting on the counter is thin, dense and hard. The same is true for the discs as we age. The thinning of the vertebral discs is the major reason why we become shorter as we age. The natural padding in the spine degenerates with age and the cervical vertebrae can be crushed together when the head is tilted back. Older adults, both men and women, have a much higher risk of osteoporosis and can easily get compression fractures of the spine. Forward bends and twists can be hazardous for someone with osteoporosis because these postures can cause painful compression fractures of the spine. "

Poses performed in a supine position can also cause neck problems in older adults. If the student has hyperkyphosis or a tight front chest, their shoulders will not reach the floor in the same way that the shoulders of a younger students do. Because of the excessive curving of the thoracic area, the student will be lying on their spine and just the tips of their shoulder blades. In this position the neck is elevated off the floor and the chin is higher than the forehead because the entire back of the head does not reach the floor. One end of a folded blanked can be rolled to go under the neck and the other side folded to support the head so the forehead and chin are at the same level thus maintaining the correct cervical curve. 

These precautions are most important for people over 70, but they are good to consider in regards to younger students who have neck injuries, arthritis of the spine, tight shoulders, over developed musculature of the shoulders, arterial sclerosis, high blood pressure or other medical conditions that could cause changes in the arteries and the shape of the upper back. 

I remind my students, “Keep your neck in a normal cervical curve and in line with your spine. Being safe is more important than looking like the picture in the yoga book.” 

—Janet Rae Humphrey, E-RYT

Thoughts on Janet’s advice: 

First off, I am grateful to Janet for sharing her wisdom and experience with us regarding safety precautions specifically for Camel pose (Ustrasana), in which the head and neck are often taken into extension along with the rest of the spine. And I generally agree with her recommendations for modifications for those over 70 and even for younger adults who may have skeletal issues like cervical problems, pronounced thoracic kyphosis (rounding of the upper back), or osteoporosis. 

Keep in mind, however, that these are not hard and fast rules, and that those who older and are healthy and without risk factors for such problems (no diabetes, hypertension, hardening of the arteries, history of past heart attacks or strokes, arthritis, osteoporosis, etc.) and have good flexibility and strength may still be able to approach the full pose, under expert guidance. 

One key factor to consider is how long you are in such poses. It seems the risks of serious adverse events rise the longer you are in such an extended position, for example, longer than 5-10 minutes. I’d recommend, if you choose to try Camel with some head and neck extension, that you do it for very brief timings, say 10-20 seconds, and use support to start with. Or, as I do now, do it with the chin tucked to the chest and enjoy the backbend in the rest of your spine! 

Also, please note that Janet is referring mostly to neck awareness and cautions for Camel pose, which involves dropping the head back in space into the pull of gravity. I don’t have the same concerns for backbends like Cobra (Bhujanghasana) and Locust (Salabasana), where you are lifting your neck up and so have different forces acting on the neck. Taking the head and neck into extension in these backbends is generally not going to put you at risk for strokes and compression fractures of the cervical area. 

—Baxter

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Friday Q&A: Safe Neck Movements

Self portrait at the age of eighty three by Hokusai

Q: was wondering if you could do a post about the safety of neck movements in older yoga practitioners (maybe 60 and up?). I teach a beginner yoga class for seniors in the Downtown Oakland Senior Center. I do like to incorporate some neck movements into our practice but just recently I got to read Swami Satynanda Saraswati’s book (Asana, Pranayama, Mudra, Bandha) and he mentions that elderly people should not do the neck movements he suggests in his Pawanmuktasana Part 1 series (chin to chest, head turning to side, ear to shoulder, head rolls (I don’t do that one with the seniors). He also suggests that cervical spondylosis patients should strictly avoid forward bending of the neck. What I mostly heard before is to be careful about back bending the neck. Would you advise patients with arthritis in the cervical spine not to do any neck movements? Or just perhaps do only 50% of their range of motion?

A: Thanks for this important question! Here at YFHA, we have written quite a bit about neck pain, neck arthritis, and normal movements of the spine, including the neck area, and other aspects of the neck (please see the end of this post for a list of recommended posts from our archives).

Before writing my answer to you, I did an online search for clear guidelines on range of motion exercises for the neck for older adults, without much luck. One study Effect of an upper-body flexibility intervention on neck range of motion in older women tried to determine if having older women practice a set of neck and upper body range of motion exercises twice a week could improve their neck range of motion. The study noted that as adults age, they often experience a decrease in mobility that can make driving a car or even safely crossing a street while checking for traffic to their right and left difficult, resulting in decreased ability to safely move about their community. They were hoping to determine a way to help turn this around. Sadly, the study did not show any significant change in neck mobility, but suggested that doing the exercises more than twice a week might change that outcome.

Before I go any further, let me clarify a few definitions for those readers new to the topic of neck problems in general:

Cervical Spondylosis: According to the Mayo Clinic Cervical Spondylosis is “a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, bone spurs and other signs of osteoarthritis develop. More than 90 percent of people older than age 65 have evidence of Cervical Spondylosis and osteoarthritis that can be seen on neck X-rays. Most of these people experience no symptoms from these problems.”

Facet Joint Arthritis: This is a form of arthritis that affects the facet joints of the neck located behind the area of the discs, and can occur alone or in conjunction to the disc changes described above.

As for the cautions that Swami Satynanda Saraswati gives in his book, I cannot directly comment on them, as I don’t have a copy of the book and I can’t check to see if he references any sources for these recommendations. However, I have some general guidelines I use when suggesting range of motion exercises to my older students.

Disc Changes

For those with significant disc changes, including Degenerative Disc Disease with symptoms or disc herniation causing symptoms, I recommend limiting forward bending of the neck, especially if any force is being applied to the neck. Examples of poses that might overload the neck for these students include Bridge pose, Rabbit pose, and even Child’s pose if the chin is tucked and the head is resting on the floor. As to whether non-weight bearing flexion of the neck is okay, such as standing in Mountain Pose and nodding the chin to the chest, careful experimentation could be tried and if there are no worsening of any neck symptoms, some practitioners might benefit from maintaining range of motion in that direction.

Facet Joint Arthritis

For those with Facet Joint arthritis that is symptomatic, extension of the neck and head (tipping the head back) can be aggravating. Therefore, caution is recommended in taking the head and neck back into extension (backbend) or extension combined with rotation. Camel Pose is an example of a neck position that I recommend be avoided by practitioners with this kind of neck arthritis. However, gentle head lifts, such as in Locust pose and Low Cobra pose, could possibly help maintain some extension range of motion in the neck while also helping to strengthen the muscles at the back of the neck. And gentle chin lifts combined with chin tucks could also be tried cautiously. Empower your students to notice the effects of the movements and make appropriate adjustments as they go along.

Basic Range of Motion Movements

It is reasonable to share some basic range of motion movements with older adults and let them monitor whether the stretching sensations that arise are acceptable or not, and allow them to limit the movements to a degree that allows the movements to be done pain free. I usually suggest simple seated or standing positions to begin. Then I have my students try simple rotation of the head and neck to the right and left, moving with the breath, which I call Owl Turns. Inhale as you turn your head to the right, exhale as you turn back to center, inhale as you turn your head to the left, and exhale as you turn back center, and repeat for perhaps 2 to 3 rounds. I usually follow that with simple side-bending movements, which I fondly refer to as Curious Dog Tips, where you inhale as you bring your right ear towards your right shoulder without letting your head rotate, and exhale as you return your head to center, and then repeat on the left side. Two to three rounds of Curious Dog Tips is a good test of how a practitioner might handle that motion.

Like our reader, I tend to avoid the head circles or head “rolls” that are sometimes taught in modern yoga classes, as these seem to have the potential to aggravate a lot of necks, young and old (see Thursday Q&A: Head Rolls).

I hope these suggestions will both give older readers of YFHA some ideas to work with and yoga teachers out them some options to share with their students.

Previous posts that can give our readers a good background understanding of the neck region of the spine include:

1. For a basic understanding of the spine as a whole and how it moves: All About Spine Anatomy and Movements 
2. For a look at pain in the neck generally: A Literal Pain in the Neck 
3. For a study on Degenerative Disc Disease, which can affect the cervical spine: Degenerative Disk Disease and Yoga 
4. A general discussion of arthritis in the spine: Arthritis of the Spine 
5. My recommendations for working with neck spasms and strains: Neck Muscle Strain and Spasm, Part 2 

—Baxter

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Friday Q&A: Is Loren Fishman's Osteoporosis Sequence Safe?

Q: You say that people should not do the same poses all the time. What about programs like Dr. Fishman's osteoporosis study, which has participants doing the same sequence of poses every single day?

A: Thanks for this question. Indeed, if a person does the same sequence day in and day out, you could run the risk of a repetitive strain injury. The fact that Dr. Fishman's sequence is only supposed to take 10 minutes a day to do means that the practitioners are not holding the poses terribly long, which would reduce this risk considerably. However, a review of the poses taught (see here) reveals several poses that I feel could be potentially injurious to the wrists, neck and lower back, these being Upward Bow pose and the deep seated forward bends. I would consider other poses if I were to design such a practice, but Dr. Fishman does mention tailoring the sequence to students individual needs. I would suspect that this had to be done quite a bit.

Recall that the number of patients that started the study was much larger than those that completed the study. (117 vs 11). Interestingly, there is no discussion as to what caused so many to drop out  and why they were unable to do a 10 minute practice everyday. One factor could have been boredom, which is why I often suggest that students alternate practices from day to day to help maintain better focus and follow through. And it is possible that some found the sequence too advanced, despite the individual adjustments offered. The bottom line, in real life, when you can vary your practice, I highly recommend you do so.

—Baxter

A: With Baxter's blessing I'm going to tell you why I wouldn't want to do this sequence on a daily basis. I'll start by telling you that the three yoga injuries I've sustained have all been repetitive strain injuries. I was a pretty enthusiastic practitioner for a number of years, and did a lot of standing poses and sun salutations. And the injuries I had were: sacroiliac joint injury (common among dancers and yoga practitioners, but not the general public), tennis elbow (possibly from sun salutations), and housemaid's knee (from kneeling too much on the bare floor).

Now let's look at the sequence:

1. Triangle Pose (Trikonasana)
2. Downward-Facing Dog Pose (Adho Mukha Svanasana)
3. Upward-Facing Dog Pose (Urdva Mukha Svanasana)
4. Bridge Pose (Setu Bandhasana)
5. Upward Bow Pose/Rainbow Pose (Urdva Dhanurasana), without or with a chair
6. One-Legged Forward Bend (Janu Sirsasana)
7. Two-Legged Forward Bend (Paschimottansana)
8. Boat Pose (Navasana)
9. Reclined Leg Stretch (Supta Padangusthasana)
10. Marichyasana 1 twist
11. Lord of Fishes twist (Matsyendrasana)
12. Reclined Twist (Jathara Parivarthasana)

After I got over the shock of trying to imagine doing all those poses in 10 minutes, without any warm-ups, I examined the poses in detail. First, two of the poses in the sequence are known for causing sacroiliac joint injuries, Triangle pose (Trikonasana) and One-Legged Forward Bend (Janu Sirsasana), with One-Legged Forward Bend a particularly guilty party. For me, personally, I've concluded it's just not good to do either of those poses every single day. Then, as Baxter mentioned, there is a very deep backbend in the sequence, Upward Bow, and doing this every day could put a lot of strain on the wrists and elbows, but of just as much concern to me is that it is followed immediately by a deep forward bend, taking the lower back into such extreme movements with no rest between. In particular, the Two-Legged Forward Bend is known for causing lower back strain. The combination of the deep backbend followed by the deep forward bend could cause a lot of back strain (personally, I would have moved the forward bends to the end of the sequence). The sequence ends with three twists, asymmetrical poses that are also hard on the sacroiliac joint, with no symmetrical counter pose to finish the sequence. (On the bright side, no danger of housemaid's knee here.)

I understand some of the thinking behind this sequence, which tries to engage all the different muscles of the body to strengthen as many bones as possible, within a short sequence, and uses the twists to "release" the back after the strain of the backbends and forward bends. However, if I were to design an osteoporosis practice, for safety's sake, I would develop five or more different sequences that the practitioner could alternate between on different days, rather than trying to cram everything into one single practice. There are so many wonderful poses in the yoga tradition, why would you limit yourself to just 12?

—Nina

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