A purported rise in yoga-related injuries in the United States has stimulated a firestorm of discussion in the yoga community, as well as a national media blitz. Over the past 20 years, yoga has expanded in popularity in the U.S. and throughout the world, bridging the gap from young to old, novice to athlete, healthy to disease-ridden and wealthy to underprivileged. While this growth is generally considered positive, the same is not true of an increase in yoga-related injuries. This article examines what may be contributing to the claimed surge in injuries, looks closely at the statistics and offers expert tips on how to cultivate a safer teaching and practice environment.
More Americans Seek Yoga for Health
In recent years, the number of American yoga enthusiasts has been steadily increasing. People are seeking yoga to feel better. A 1994 Roper Poll found that 6 million Americans practiced yoga (Cushman 2000). A 2002 National Health Interview Survey (NHIS) reported that approximately 10.4 million adults were participating (Birdee et al. 2008). The 2007 NHIS revealed that 13.17 million adults had practiced yoga in the previous year, and for the first time this report included a measure of children (1.5 million) (Barnes, Bloom & Nahin 2008). In the 2008 “Yoga in America” market study, released by Yoga Journal, the figure climbed to 15.8 million, or 6.9% of American adults (Yoga Journal 2008). A year later, 20.1 million Americans aged 6 and older were participating in yoga and yoga-related activities, according to the Sporting Goods Manufacturers Association (SGMA 2010). And in 2010, that number had risen to 21.9 million, representing an 8.8% growth over the previous year (SGMA 2011). Both the Yoga Journal and the NHIS reports noted that the majority of Americans were doing yoga for health improvement (Yoga Journal 2008; Barnes, Bloom & Nahim 2008; Birdee et al. 2008).
According to the National Center for Complementary and Alternative Medicine (NCCAM), people use yoga for a variety of health concerns, including a specific desire to cope with anxiety, stress, asthma, high blood pressure or depression, or a more general need to maintain health, improve fitness and relax (NCCAM 2008). Data analysis of the 2007 NHIS report showed that Americans spent $4.1 billion on yoga, tai chi and qigong classes in 2007. This figure represents 12% of the total out-of-pocket sum that Americans spent on all complementary and alternative medical products and services that year (NIH 2009). In another important development, identified by the “Yoga in America” survey, 6.1% of Americans said a healthcare practitioner recommended that they try yoga (Yoga Journal 2008).
There are two trends fueling growth. One is medical practitioners’ acceptance of yoga as a means of benefiting health; the other is a desire of more Americans to take responsibility for self-care and to seek tools to optimize well-being. “Yoga as medicine represents the next great yoga wave,” wrote Kaitlin Quistgaard, editor in chief of Yoga Journal, in 2008 (Yoga Journal 2008). The journal’s publisher, Bill Harper, stated, “Yoga is no longer simply a singular pursuit but a lifestyle choice and an established part of our health and cultural landscape. People come to yoga and stick with it because they want to live healthier lives” (Yoga Journal 2008).
These words have held true. Yoga therapy is experiencing its own rapid growth, reflected by a 41% increase in training school memberships between 2010 and 2011 in the International Association of Yoga Therapists (IAYT), a professional organization serving yoga teachers and yoga therapists (Kepner 2012).
Are Yoga Injuries on the Rise?
To determine whether yoga injuries are actually increasing, let’s take a look at the data. According to the U.S. Consumer Product Safety Commission, 5,353 people were treated in hospitals, doctors’ offices and emergency rooms for yoga-related injuries in 2002 (USCPSC 2012). In 2007, the number was 5,366 (USCPSC 2012). Considering that the absolute number of adult yoga practitioners increased by almost 3 million during that period, the incidence of injury as a percentage of the people doing yoga actually decreased. And while it is true that in 2010, a reported 7,948 people were treated for yoga-related injuries (USCPSC 2012), between 2007 and 2010 the number of practitioners (adults and children) rose from about 14.67 million to almost 22 million.
Therefore, while it is factually true to state that the number of yoga-related injuries is increasing, it is not at all clear that the percentage of people who are becoming injured from practicing yoga is rising. In other words, the rise in numbers may simply be due to an increase in participation. “I do believe that there is a perceived escalation of yoga-associated injury,” says Marla Ericksen, RYT® 500 and E-RYT 500, owner and director of Empower ME Yoga Studio and Training Academy in Ottawa. “In my opinion, the fact that we are seeing injury more now than in the past is simply a reflection of the popularity of yoga and the massive increase in the number of yoga practitioners.”
Stacy McCarthy, E-RYT 500, yoga director for the Yoga School of Business and adjunct faculty member for the Miracosta College yoga certification program, in Oceanside, California, agrees. “There is likely some increase in yoga injuries, because there are so many people practicing yoga now. Compared with other physical activities, the [number] of serious injuries that happen with yoga [is] extremely low.”
A quick glance at injury rates in other activities confirms McCarthy’s point that the number of yoga-related injuries is quite low. For example, in 2010, more than 75,000 Americans, or almost 10 times the number of people who experienced yoga-related issues, were treated in hospitals, doctors’ offices and emergency rooms for gymnastics injuries (AAOS 2012). More than 414,000 were treated for baseball-related injuries (AAOS 2011). A 2002 Centers for Disease Control and Prevention (CDC) report indicated that an estimated 4.3 million sports and recreation-related injuries were being treated each year in hospital emergency rooms alone (CDC 2002). The conclusion from the CDC report was that more efforts were needed to reduce injury risks from all sports and recreation activities among all population groups.
The effort to reduce risks in yoga practice—as in any activity—is a critical endeavor, not only for public protection, but also for the responsible and sustainable growth of yoga. The CDC suggests that interventions to reduce injury risk in sports and recreational activities can broadly be defined in three categories: personal countermeasures (such as use of safety gear), behavioral interventions (such as proper conditioning for the activity) and environmental modifications (such as padded surfaces where contact may occur) (CDC 2002). Additional safety measures are activity-specific, as identified by research.
While CDC tips provide helpful tools for analyzing sports and recreational activities in general, we can also look to the philosophy and teachings of yoga itself for guidance. “I see more clients with injuries now than in the past 20 years, simply because more people are doing yoga,” says Claudia Micco, E-RYT 500, YogaFit® master trainer and lead trainer at the Ritz Carlton Spa and Fitness Center in Maui, Hawaii. “I also often see students approach the practice with less of the ‘contemplative’ mindset of past decades and more of the ‘boot camp’ approach that is currently popular.”
Has Yoga Strayed Too Far From Its Roots?
While it’s difficult without comprehensive research to know exactly how and why people are experiencing injuries from yoga practice, experts cite a number of factors. These range from the influence of our fast-paced, competitive society and our emphasis on “physical culture” to the lack of in-depth yoga instructor training. The challenge is multilayered—from the complex issue of defining what constitutes ‘authentic yoga’ to the fact that the yoga “market” is self-regulated.
The Yoga Alliance® (YA), a nonprofit national education and support organization, represents efforts by yoga community leaders to offer some self-regulation. The YA works in the public interest to ensure that people have a thorough understanding of yoga’s benefits; that yoga teachers value its history and traditions; and that the public has confidence in the quality and consistency of instruction. To achieve this mission, in 1999 the YA established a national yoga teachers’ registry to recognize instructors who meet minimum education standards. These standards require training in yoga techniques, including asanas, pranayamas, kriyas, chanting, mantras, meditation and more; teaching methodology; anatomy and physiology; yoga lifestyle, philosophy and ethics; electives consistent with the particular yoga school’s tradition; and practice teaching. Teachers who meet these standards can register as Registered Yoga Teachers (RYTs). Those with significant teaching experience in addition to training may register as Experienced Registered Yoga Teachers (E-RYTs) (Yoga Alliance 2010).
The YA, however, is not a certifying association but rather a peer organization whose standards are “intended to strengthen the integrity of a Registered Yoga Teacher (RYT) or a Registered Yoga School (RYS®) in the yoga community and to enhance public perception of yoga teachers as well-trained professionals” (Yoga Alliance 2010). Managers of studios, health clubs and other facilities are not required to hire instructors who are registered with the YA, nor are they necessarily aware of the qualitative differences in the varieties of yoga teacher training.
Another challenge is that the practice of physical postures, or asanas, represents only one small fragment of yoga. When people separate physical postures from the more comprehensive philosophical system and treat asanas like calisthenics, much of the essence of what makes the postures “yogic” is lost. In other words, yoga postures are no longer the practice of yoga if the integrative foundational approach that includes mind, body and spirit is not included.
That the demand for yoga is outpacing the ability to train and supply instructors in a way that honors tradition is another factor contributing to injuries, notes Ericksen. “It’s inevitable that there are more teachers with less experience teaching more people. As a result, the yoga that is being presented to the masses is subject to a process that affects the purity and potency of time-honored practices.”
To further complicate matters, many who come to yoga do not fit the profile of the typical “apparently healthy” person who joins a fitness facility; instead, they are specifically seeking a practice that will help them cope with pre-existing conditions. “Students may hear that yoga is ‘therapeutic’ and [seek] out yoga because it was suggested that they heal their back, knee or hips with a ‘less stressful’ exercise approach,” says Jill Miller, E-RYT, creator of Yoga Tune Up® in Los Angeles. “Unfortunately, for many of these students, yoga, like any exercise, can have an adverse effect if practiced without a sense of their own weaknesses and limitations, coupled with not knowing which poses are helpful and which are hurtful for their particular body.”
Yoga is also attracting more fitness-oriented participants than in the past, and these participants are stimulating demand for more athletic classes, where injury risk can be greater. Liz Dene, instructor trainer for Byron Yoga Centre and the Australian Institute of Fitness, and an international presenter, based in Sydney, says, “Dynamic classes are fantastic if taught correctly and students are experienced in this type of practice. Too often, this is where students start with no yoga knowledge or understanding of the gradual and layered process of yoga. Sometimes, especially for those who like to train hard and want results, it is hard to leave the ego behind . . . we have often had new students thinking they will be doing freestanding headstands by next week.”
Other experts think current teacher-training standards are not stringent enough to qualify instructors to teach participants who have a host of pre-existing conditions and are often referred by medical practitioners. “The YA requires only 20 hours of education in anatomy and physiology,” says Lauren Eirk, E-RYT 500 and president of Yoga I.S.® instructor education, based in Louisville, Kentucky. “This is not enough to understand how to adapt postures for the variety of people who are coming to take yoga.” Miller agrees: “Anatomy must be taught as an embodied approach, meaning students develop a kinesthetic sense of where their tissues are located and what they feel like from the inside out; in other words, [they become] ‘sense-smart.’ And they should also have the intellectual understanding of anatomy from the outside in—‘book-smart.’”
While yoga community leaders may debate the details of what it takes to prepare and qualify competent yoga instructors, many agree that yoga needs to return to its true essence—an integrative path of self-realization rooted in a philosophy that includes mindfulness to develop higher-conscious awareness and that uses a variety of techniques such as breathing exercises, visualization, mantras, meditation, chanting, service, study and the practice of physical postures, among other disciplines. Experts agree that an overly physical emphasis on posture practice alone, combined with pressure to achieve media images of physical perfection, is a formula for injury. The damage can manifest instantly in torn muscles, tendons or ligaments, pinched nerves or—in extreme cases—a stroke, or it can present over time as injured tissues or chronic joint pain.
How to Teach Yoga Safely
Experts offer many suggestions for improving asana teaching and practice safety. While specific tips follow, see the sidebar on the yamas and niyamas to gain insight into how yoga principles provide guidance on injury avoidance.
- Obtain a medical release before participating in yoga if a medical issue is present.
- Use props as needed to support modifications.
- Wear comfortable, breathable clothing and use sticky mats or sticky socks to avoid slips.
- Avoid overeating before class and stay hydrated by drinking water as needed.
- Limit external distractions like loud noises or visual stimuli that can disrupt concentration.
- Ensure good visibility and acoustics so teaching instructions are seen and heard clearly.
- Provide safe room temperatures suitable for participants.
- Provide water.
- Ensure good ventilation.
- Limit class size to permit enough space for postures that require more movement or that may result in someone taking a tumble (e.g., headstand, shoulder stand or other arm-balancing positions). Make sure all floor and wall surfaces are safe.
Individual Limits and Behaviors
- Encourage students to develop a sense of embodied movement and to take responsibility for what they are experiencing in their own bodies.
- Know (students and teachers alike) who should not do inversions; for example, people with glaucoma, a detached retina or high blood pressure. Also know who should not do backward bends or put pressure on the cervical spine. Pregnant women as well as individuals with osteoporosis, high or low blood pressure, inner-ear problems or known degenerative problems are at greater risk for injury.
- Promote mindfulness or present-state awareness. Accept that there is a learning curve and that a progression is required to all stages and expressions of a pose.
- Discourage use of force or extreme effort to achieve a body position; instead, encourage attunement to inner body signals and the breath to find alignment that is in harmony with the body’s true capacities at that moment and that provides a feeling of comfortable effort.
- Undertake special training before teaching children, prenatal or postpartum women or anyone with a medical or chronic condition.
- Explain to participants that for some body types and genetic predispositions, the full expression of certain postures may never be possible, but that does not mean that modified versions do not offer multiple benefits.
- Foster a safe, noncompetitive environment in which each participant is encouraged to work at his or her own pace and is provided with personalized options.
- Provide a thorough warm-up with attention to active range of motion for all joints.
- If a class is too large to provide individual attention during all postures, avoid more risky and/or complex postures in which someone could strain a back, neck, hip or knee.
- Avoid sustained forward bends or pushing to the extreme end range of motion in any position.
- Exercise caution with any flow-style programs. Rapid changes from one posture to another may not allow people time to achieve proper alignment.
- Vary the order of asanas, offer options and teach progressively.
- Stay up-to-date on research in yoga and in biomechanics.
Popular demand for yoga is life-affirming and reflects people’s strong need to find tools for self-improvement—physically, mentally and spiritually. Minimizing risks while enjoying yoga’s benefits is crucial. While some people may struggle with or debate what constitutes a spiritual practice against a backdrop of institutionalized religions, few can question the value of seeking to realize one’s best self in mind, body and spirit. With that perspective, those who teach and practice yoga can continue to celebrate yoga’s integration of mindful, physical and spiritual tools and to ensure that the practice of physical postures is not divorced from the more meaningful context from which they emerged. This commitment alone is likely to reduce injuries and enhance self-restoration. In yoga itself are answers to questions that yoga provokes.