More than a fitness fad:
Yoga as medicine
By Gail Dubinsky, MD
Yoga, an ancient practice from India, has exploded in popularity over the last 20 years. When I first relocated from the San Francisco Bay Area to Sonoma County and began teaching yoga in 1990 at a health club in Cotati, there were virtually no other local gyms that offered yoga classes. At first, there were weeks when only two or three people showed up. Looking to teach in Sebastopol, there was one class at the community center and another private class out of that teacher’s home, and I started my new class on martial arts mats in a converted warehouse. Ten years later, my now twice weekly health club class had 20 plus regular students, and yoga classes could be found every day of the week in at least six venues in just Sebastopol alone, including my own studio space near my office on South Gravenstein Highway.
Today, there are hundreds of classes weekly all over Sonoma County: in health clubs, yoga studios, private spaces, hospital educational centers, and corporate campuses. A veritable panoply of yoga options exists to choose from: Bikram (hot), Iyengar, Vinyasa (flow), Viniyoga, Power, Restorative, Kundalini, and various other derivative Hatha (basic) styles.
So why is yoga so popular? How has yoga gone from the latest alternative fitness fad to becoming main stream? What evidence is there for its many purported physical and psychological benefits? Are there pitfalls, hazards, or contraindications?
What exactly is yoga?
When I ask new students or attendees of lectures or workshops what yoga means to them, typical responses include stretching, strengthening, relaxation, breathing, stress reduction, meditation, or spirituality. Actually, the meaning of the word Yoga derives from the Sanskrit word “yug”— to bind, to yoke, to bring together. It is mostly translated as meaning “union.”
The Yoga Sutras of Patanjali, a key text dating back to 400 BC to 400 AD, consists of brief aphorisms compiling and reformulating the oral tradition of centuries of Indian philosophy and psychology. It presents the practice of yoga as a finely delineated blueprint for rising above the false attachments, illusions, and entrenched processes of our minds. Yoga is clearly defined as the cessation of the fluctuations and thought waves of the mind, so that one can see one’s true nature, and know oneself as he or she really is, always has been and always will be: our finite self is one with the Infinite Self. Rather than endeavoring to become something “better” or “more spiritual,” the practice serves to remove all the impediments toward realizing the state of union and connection that is our birthright. (I like to say it is the opposite of “original sin!”) However, yoga is most definitely not a religion. Although it comes from India, with predominantly Hindu cultural and religious influence, there is no alignment or conflict with any established religion. In fact, in modern times, Paramahansa Yogananda (Autobiography of a Yogi) incorporated many Judeo-Christian references and principles in his teachings.
Uniting mind and body awareness
The only reference to any yoga postures (“asanas”) in the Yoga Sutras is that they “should be steady and comfortable.” (Looking at some yoga calendars or magazines, one wonders how many “normal” people would find those positions such! ) However, asanas were actually a much later development in the yoga tradition, basically as a means to help practitioners be capable of sitting for long periods of meditation. Classical Yoga consists of eight “limbs,” beginning with Yama and Niyama, moral principles of relationship to others and to yourself (concepts such as non-violence, truthfulness, moderation, and non-greed); Asana, and Pranayama (breath control practices). The remaining limbs are the successive stages of meditation: withdrawal of the senses (from input from the outside world), concentration, merging with the object of meditation, and pure consciousness. (Most of us don’t quite reach these latter two!)
In our western, physically oriented (and sometimes superficial) culture, yoga has been largely reduced to its physical component, a way to be more fit, beautiful and sexy, with yoga mats a hip fashion accessory. But there is no denying that the vast majority of us initially come to yoga because of physical pain or discomfort. Soon however, if the yoga is not merely one of the more formulaic, vigorous “physical” styles, most practitioners come to realize that there is something far deeper to be gained, in terms of self-integration, inner peace, or expansion, more than just simply relaxation. Beyond the stretching, strengthening and improving balance and posture, becoming more aware of lengthening and deepening the breath begins to balance the autonomic nervous system out of chronic sympathetic or “fight or flight” dominance – our current universal societal malady. Incorporating more specific meditation practices can enhance these positive physiological and psychological benefits.
Is yoga indeed “medicine”?
“Since the primary goal of yoga practice is spiritual development, beneficial medical consequences of yoga practice can more precisely be described as positive side effects.” (1) A steadily increasing body of research (2) supports claims of yoga’s benefits in multiple conditions: back pain, arthritis, depression, anxiety, insomnia, headaches, pulmonary conditions, diabetes, gynecological issues, cancer, and more.
It must be said that there are significant methodological challenges to yoga research. It is obviously not feasible to perform randomized, double blind studies on yoga. There is rarely funding to assess results over a significant length of time. Most yoga classes in a research study are taught with a specific, reproducible protocol of poses and practices, a somewhat artificial situation as compared to most classes or private sessions which address the particular needs of the students at the time. Study design can range from studying physiologic or psychological parameters before, during and after a yoga practice; comparing a yoga group to a “wait list” control group, or comparing yoga and other modalities such as physical therapy or patient education. Study sizes can be amazingly small. Yoga styles and practices utilized are not uniform. Some studies involve only the postures, others incorporate breath practices and meditation techniques. Even so, there is still ample evidence to suggest that yoga is a healing therapy that deserves a place in the health care continuum.
What about yoga injuries?
Since yoga is in greater or lesser part a physical practice, even if sitting for long periods in meditation, it is inevitable that sometimes injury can occur. In that sense, it is no different than any other activity, such as running, cycling, or playing soccer. Accidents can happen, or cumulative strains and damage can develop from poor training, faulty alignment, or pre-existing conditions such as hypermobility. Few serious yoga practitioners of many decades have not had some experience of injury. But in fact, considering the sheer number of people who practice yoga, the rate of injury is very small. And, in my view, the potential for harm is vastly outweighed by the many benefits of yoga on so many levels.
How to minimize the risk? Remember the “Yamas” described previously? If one applies the principles of non-violence, truthfulness, moderation, and non-greed, as well as staying keenly self-aware while practicing yoga, there is much less likelihood of excess pride, competitiveness, trying to keep up with fellow students, or going beyond one’s capabilities at a given time. These factors play a very large role in yoga injuries. While staying present in one’s body and mind is required to reap the benefits of yoga, it is even more so to prevent or reduce risk of injury. It is a fine line between a healthy challenge and unsafe practice. Self-awareness and staying connected to the breath are key!
Finally, a highly trained and attentive instructor is essential to help students maintain proper alignment, reduce straining, and modify asanas for individual needs or limitations. Although the standard advice is for prospective yoga students with any possible limiting physical conditions to get clearance from their physicians, most are not familiar enough with the variables of yoga to give an informed consent, so to speak. Far more important is to share with any yoga instructor your history of significant medical conditions, trauma, or current musculoskeletal and spinal conditions so that the instructor may be able to provide any assistance or adaptations necessary to make our yoga experience as safe, therapeutic, and fulfilling as possible. In fact, whether for those with more significant musculoskeletal or medical issues, or merely the most inflexible, “out of shape” or disconnected “neophytes,” usually just the very simplest yoga asanas, breathing and relaxation techniques provide the most profound rewards in body, mind, and spirit.
- Goyeche, JR “Yoga as Therapy in Psychosomatic Medicine”, Psychother Psychosom 1979;31:373-381
- Yoga As Medicine, Timothy McCaul M.D. 2007 iayt.org (International Association of Yoga Therapy)
About the author: Gail Dubinsky, MD has practiced orthopedic medicine in Sebastopol and taught yoga in Sonoma County for the past 21 years. She is the creator of the yoga programs Rx: Yoga! (CD), RSI? Rx:Yoga! and Yoga for Gardeners (DVDs). A presenter on Yoga for Chronic Pain at the Institute for Functional Medicine 2008 Symposium, she currently teaches “Yoga for Chronic Pain Management” at the Center for Well Being in Santa Rosa. For more information, visit gaildubinskymd.com.