For some reason the NYT is all about neck injury lately. In yesterday’s discussion of a possible chiropractic induced injury, Russell asked:

But given all the other stresses people put on their necks, from accidents such as headbumps, from purposeful athletics such as whacking soccer balls, and from just craning one’s head in odd positions when performing various kinds of mechanical labor, it puzzles me that the risk from a chiropractor would be much greater than the risks from these other kinds of use/abuse. Of course, this is not excuse for the chiropractor, who is imposing that risk, likely on those more susceptible to injury, under false pretense or treating disease. It’s more a general lament that we each carry so much haphazard anatomy.

Interesting he should mention this as today the NYT has an article How Yoga Can Wreck Your Body describing many ways that neck hyperextension during this popular exercise can also create similar injuries to the vertebral and carotid arteries.

The mechanism is similar…

From the article, a discussion of a small literature describing yoga induced injuries emphasizes the importance of not taking big risks with your neck:

In 1972 a prominent Oxford neurophysiologist, W. Ritchie Russell, published an article in The British Medical Journal arguing that, while rare, some yoga postures threatened to cause strokes even in relatively young, healthy people. Russell found that brain injuries arose not only from direct trauma to the head but also from quick movements or excessive extensions of the neck, such as occur in whiplash — or certain yoga poses. Normally, the neck can stretch backward 75 degrees, forward 40 degrees and sideways 45 degrees, and it can rotate on its axis about 50 degrees. Yoga practitioners typically move the vertebrae much farther. An intermediate student can easily turn his or her neck 90 degrees — nearly twice the normal rotation.

Hyperflexion of the neck was encouraged by experienced practitioners. Iyengar emphasized that in cobra pose, the head should arch “as far back as possible” and insisted that in the shoulder stand, in which the chin is tucked deep in the chest, the trunk and head forming a right angle, “the body should be in one straight line, perpendicular to the floor.” He called the pose, said to stimulate the thyroid, “one of the greatest boons conferred on humanity by our ancient sages.”

Extreme motions of the head and neck, Russell warned, could wound the vertebral arteries, producing clots, swelling and constriction, and eventually wreak havoc in the brain.

A healthy woman of 28 suffered a stroke while doing a yoga position known as the wheel or upward bow, in which the practitioner lies on her back, then lifts her body into a semicircular arc, balancing on hands and feet. An intermediate stage often involves raising the trunk and resting the crown of the head on the floor. While balanced on her head, her neck bent far backward, the woman “suddenly felt a severe throbbing headache.” She had difficulty getting up, and when helped into a standing position, was unable to walk without assistance. The woman was rushed to the hospital. She had no sensation on the right side of her body; her left arm and leg responded poorly to her commands. Her eyes kept glancing involuntarily to the left. And the left side of her face showed a contracted pupil, a drooping upper eyelid and a rising lower lid — a cluster of symptoms known as Horner’s syndrome. Nagler reported that the woman also had a tendency to fall to the left.

Her doctors found that the woman’s left vertebral artery, which runs between the first two cervical vertebrae, had narrowed considerably and that the arteries feeding her cerebellum had undergone severe displacement.

The experience of Nagler’s patient was not an isolated incident. A few years later, a 25-year-old man was rushed to Northwestern Memorial Hospital, in Chicago, complaining of blurred vision, difficulty swallowing and controlling the left side of his body. Steven H. Hanus, a medical student at the time, became interested in the case and worked with the chairman of the neurology department to determine the cause (he later published the results with several colleagues). The patient had been in excellent health, practicing yoga every morning for a year and a half. His routine included spinal twists in which he rotated his head far to the left and far to the right. Then he would do a shoulder stand with his neck “maximally flexed against the bare floor,” just as Iyengar had instructed, remaining in the inversion for about five minutes. A series of bruises ran down the man’s lower neck, which, the team wrote in The Archives of Neurology, “resulted from repeated contact with the hard floor surface on which he did yoga exercises.” These were a sign of neck trauma. Diagnostic tests revealed blockages of the left vertebral artery between the c2 and c3 vertebrae; the blood vessel there had suffered “total or nearly complete occlusion”

Two months after his attack, and after much physical therapy, the man was able to walk with a cane. But, the team reported, he “continued to have pronounced difficulty performing fine movements with his left hand.” Hanus and his colleagues concluded that the young man’s condition represented a new kind of danger. Healthy individuals could seriously damage their vertebral arteries, they warned, “by neck movements that exceed physiological tolerance.” Yoga, they stressed, “should be considered as a possible precipitating event.”

The mechanisms of all of these injuries and that of neck hyperextension by a chiropractor are similar, and have to do with an unfortunate quirk of neck anatomy. The vertebral arteries, which feed the posterior portion of the circle of Willis and much of the posterior structures of the brain, travel through a thin bony canal in the spinous processes of your cervical vertebrae. i-c750d8e49168bd818e17211e9beaeab6-vertebral artery.png (Image via the full wiki)

When the neck is stretched or rotated in the course of normal movements there is plenty of give in the artery and between the sites of fixation of the spinal processes, but with extreme rotation or hyperflexion the artery can be dangerously stretched between two fixed points. The common injury is a dissection – the formation of a flap within the artery from a tear in the wall. It would be unusual for an artery to completely tear open with extravasation of blood, but the flap created from a dissection is dangerous because it can be a source for clots causing embolic strokes, as well as occlusion of the vessel or extension of the dissection with risk of rupture. I have seen these injuries from motor vehicle accidents when there is a whiplash injury of the neck, and they can be quite serious.

The point here isn’t to disparage Yoga which can be healthy exercise, and probably a lot safer than bicycle riding on busy streets or running at night. But people should know the limits of what the body can do, and be very careful about injuring certain areas of the body which can be devastating. Be very careful with your neck and head. Wear helmets when traveling at speed. Wear a running vest at night so you don’t get clocked by a drunk. And when some Yogi comes along and says putting your body weight on the back of your neck is a panacea and will cure your thyroid? Tell them to shove it.

Comments

  1. #1 Russell
    January 6, 2012

    An interesting aspect of this anatomy is that the circle of Willis provides some degree of redundancy to loss of supply from the arteries that feed it. So much so that some people will have complete occlusion of the carotid on one side, without knowing it. Of course, a clot that passes through the circle will cause a stroke downstream of wherever it lodges beyond.

    You raise a curious point. Neck movement, more than most joints, seems limited by comfort. Both flexing and extending my lower arm, the elbow reaches “hard stops” where the muscles just can’t further move the limb. And similarly with rotation. And equally for the knee and ankle and most joints. With the neck, that seems much less the case. Personally, I find a “hard stop” only dipping my head forward, when my chin digs into my sternum.

  2. #2 Fitness equipment
    January 7, 2012

    Interesting read

  3. #3 Bob Woolery, DC
    January 7, 2012

    Neck adjustments can be accomplished without extension/rotation. Some of us in the profession feel that the supine rotary mechanism cervical adjustment should be de-emphasized, if not outlawed. While these adjustments are much less dangerous than they appear, better, less potentially traumatic methods have been developed in the 90 or so years since these rotary moves were all we had. Toggle, NUCCA, Gonstead, Activator, and more are procedures that allow correction without forceful rotation.

  4. #4 Margaret Heller DC
    January 8, 2012

    Great perspective from a lay person – I get to see this on a daily basis. It seems that only my malpractice insurer knows for sure. Malpractice insurance is dirt cheap for chiropractors so I can only surmise we are not the ones hurting people. Most people pay more in a month for health insurance than I pay in a year for malpractice. As a matter of fact – I bet The NYTimes causes more injuries and strokes than chiropractors and yogis put together and they are just trying to deflect the heat!

    Also I love when they call a neurosurgeon “prominent”. I am going to start using that! “The prominent chiropractor, Margaret Heller, D.C., said……”

  5. #5 harold
    January 8, 2012

    First comment on this blog; I am a pathologist by training.

    I was most underwhelmed by this article. In fact, it had strong elements of quack promotion – the guy being quoted teaches yoga to “celebrities”, and a major point of the article was that he, and he alone, has the mysterious expertise to help you avoid injury.

    Reality –

    Of course all exercise has the potential to cause injury. Poor judgment on the part of exercisers, and poorly trained or aggressive/judgmental instructors or trainers, are always risk factors.

    However, a sedentary lifestyle is also a risk factor for many conditions. As always, it’s a cost/benefit analysis. All exercise has some injury potential – go out for a brisk walk, and you could trip, strain a muscle, injure connective tissue, be attacked by an animal or human predator, be exposed to a pathogen, etc. It’s just that being sedentary carries a higher risk (and also, that exercise can be enjoyable).

    “Yoga” as usually used, in the context of exercise*, refers to an overlapping but diverse group of regimens, which tend to emphasize holding postures, in a way the may markedly increase flexibility, moderately improve strength, and have typical exercise benefits on such markers of health as blood pressure, etc. The literature is somewhat scattered due to the diversity of yoga regimens, and probably biased toward seeking benefits, but is generally supportive of yoga regimens as a potentially beneficial part of a healthy lifestyle.

    Many yoga instructors have a good ability to recommend different levels of intensity, depending on the age and condition of the participant.

    Advocates of the various yoga regimens sometimes, predictably, claim that they advocate “true” yoga and that other styles are dangerous. Some condemn “inversions”, others promote them. Hot room “Bikram” yoga poses an obvious risk of dehydration to anyone who is foolish enough to practice it and not hydrate properly.

    Nevertheless, there is, as far as I can tell, no persuasive evidence that yoga regimens, nor even any single regimen, cause or causes excessive injury, relative to other types of exercise.

    My guess would be that yoga, overall, probably carries more risk than walking and some other low impact activities, but less than running or most competitive sports, and that the risk of injury in yoga can be controlled.

    Arguably more research is needed, although given the apparent paucity of serious yoga-related problems, despite its popularity, research dollars might be better spend elsewhere.

    *Yes I know it can also refer to broad areas of dharmic philosophy.

  6. #6 Gary M
    January 9, 2012

    Never knew yoga was so dangerous! ;-) It is important what you said that people should listen to their bodies and know what their limits are. Great article, well written!

  7. #7 Yoga Teacher Ashley
    February 13, 2012

    As a yoga teacher, I feel that I need to chime in here. Yes, yoga can cause an injury but its about how you approach the practice. The biggest challenge for us teachers is that many people come to our class in such a rush that this “rush approach” is what can cause more harm. People leave their office on high speed and then come into my studio expecting me to just fix them. Then they do something wrong and blame us the teacher or yoga as a practice. Thats like getting mad at your computer when you spill something on the keys. People need to accept responsibility for themselves and stop blaming something other then themselves. Yoga has proven to heal and yes it can cause injury but its about how you go about it. Take it slow, breathe, and ease into your poses rather then forcing yourself into them

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