CHAPTER 6 The basic exercises

General introduction: basic exercises

How to use the basic exercise section

In the section on yoga and health in Chapter 1, we emphasized finding and developing healthy structures in the body as a fundamental approach for therapeutic yoga. To learn how to use these structures in a sensible way to improve their function we have applied the principles of mindfulness, variety of exercise approaches, economical practice, precision, and finetuning to the exercise approach. Specific aims for improving bodily structure and function are mobility, strength, stamina, relaxation, balance, coordination, synchronization, and breathing naturally.

The instructions are designed in order to achieve healthy postures and movements. Nevertheless students and patients will need guidance to stay within this healthy range or to move back a level by using appropriate props.

Our experience with patients’ motivation has shown (see also Chapter 4):

• The learning steps must be small enough so that patients can improve in line with their ability.

• However, they should be challenged as far as possible, so that they do not become bored.

• They should see success early onto motivate them to continue. This experience of success should come from their performance of the exercises and be confirmed by the therapist.

• They should understand why they are practicing the chosen exercises.

• They should enjoy the exercises and look forward to continuing to practice them. The therapist or instructor who is teaching the exercises should also enjoy the process.

The therapist’s own posture and movement patterns should set a good example. This is important for patients and also to protect therapists and teachers, who should themselves be in good condition, and only teach from their own experience and understanding.

We have collected together this set of basic exercises as a tool for therapists, instructors, and patients. The exercises are divided according to the areas of the body. This is not a strict division; rather it is a focus. Some exercises are similar for different areas, focusing on different areas, sensations, or movements. A different emphasis or applying a prop in a different way brings the focus to another area. For example, in supported forward bending, placing a rolled blanket underneath the lower abdomen targets the lumbar spine (exercise 1.7, Figure 6.13), whereas placing the rolled blanket underneath the costal arches targets the dorsolumbar junction and the lower ribs (exercise 2.7, Figure 6.49). For each area there are exercises emphasizing one or more aims. These aims are stated at the start of the exercise. In each and every exercise you should aim for a good quality of breathing. The rib exercises are particularly helpful to improve breathing.

These basic exercises are modified from more complex yoga āsanas or their preparation. Most of these basic exercises are teaching details of āsanas and help us to understand fine adjustments of the āsanas. Even if the exercises are small and subtle it is important to integrate them into a good all-over posture while working with the whole body in a sensible way. An important example is to maintain a stable position of the pelvis and keep the spine lifted while practicing exercises for the thorax, shoulders, cervical spine, or head. Therefore these basic exercises are yoga exercises, too, particularly as we put a great deal of emphasis on applying the principles of mindfulness, variety of exercise approaches, economical practice, precision, and finetuning during exercising. All the principles are relevant for all exercises, and should be applied during practice. Mindfulness is paramount among the principles (see Chapter 2) and particularly connects to the spirit of yoga. It underlies all the other principles: variety, economical practice, precision, and finetuning.

The exercises are not meant to be carried out one by one as presented here. They can be selected and combined for each patient according to the diagnosis. The sequences should gradually increase in intensity and finish with a quiet exercise or Śavāsana (see Chapter 7). Some of the basic exercises have several variations. This was designed to cater for the great variety of anatomical shapes and movement possibilities, to meet individual needs.

As emphasized in Chapter 3, it is essential to carry out a thorough case history and examination, including contraindications in certain conditions. Keeping in mind your patient’s particular aims and selecting and applying the exercises accordingly, this approach can be applied to many conditions. In particular it is useful to help target restricted areas and protect hypermobile ones, which is fundamental in many musculoskeletal problems. Patients who have many symptoms will probably already have had a lot of therapy. Do not add more; rather start the patient on exercises he can still do to encourage him. Other exercises can gradually be added to help the body correct itself and improve the patient’s chance of self-healing.

It is important to respect patients’ abilities and restrictions. Many of the exercises can be modified to meet the needs of different patients. If, for example, patients find it impossible to lie down or get up from the floor, they can practice the exercises on a bed or couch or table. It is also worth thinking about exercises that improve getting up. If patients cannot lie flat, particularly older patients or those with circulatory problems, many of the supine postures can be modified with the head or thorax raised. Many modifications for positioning patients on the treatment table can also be applied to exercise positions, and throughout the practical sections we have given suggestions for using props. There are countless variations to modify and adjust exercises to individual needs. As mindful exercising is one of our fundamental exercise principles, awareness and feeling are important guides when building up and modifying the exercises. Considering these possibilities of modification, this exercise approach is suitable for patients with many different kinds of restrictions and for all age groups.

The recommended timings and number of repetitions are based on long-term observations, what feels right for many patients, and on research results (Pullig Schatz 1992, Tanzberger et al 2004, Lederman 2005). However, the results vary within a range of possibilities: again, careful observation and mindful exercising will be a helpful guide. Frequently used timing for holding stretches or strengthening is 3–5 breaths, for repetitions of basic exercises 3–5 times. Unless directed otherwise, by breath we mean one inhalation and one exhalation. For beginners the time may be shorter, gradually increasing with practice. Within a sensible range it also depends on the desired effect. The lengthening of a muscle in a relaxed position may take much longer, depending on the individual situation. It usually takes several minutes to get into deep relaxation. So it is important that the therapist and the patient are clear about the aims of the exercises and understand the principles.

Exercises should not be held so long or repeated so often that the patient becomes exhausted or uncomfortable. Ask patients how they feel, and then adjust the intensity, timing, and way of performing the exercises according to the feedback. If a stretch is painful, modify the challenge so that it becomes tolerable. After exercising patients should feel comfortable. If they feel continuing pain after exercising, they should be referred for medical investigation (see Chapter 3). If the results are negative, check again that the patient is carrying out the exercises correctly, and perhaps make the practice shorter or less intense.

Many basic exercises are suitable for beginners. There are refined or stronger versions for experienced practitioners, indicated at the start of the exercise. However, advanced practitioners may not need harder exercises than beginners. Each exercise can be performed and experienced very differently depending on the level of practice. To begin with the exercise approach will be less detailed, more like building a frame. With increasing practice you come closer to the inner work, refining the movements and sensations, connecting more and more layers of the body. This can all be done within one exercise. Different patients have different needs and wishes. Some only practice basic exercises for a long time and make good progress. Others need different exercises to move ahead. Even without any variations the beginners’ exercises will be experienced differently and understood in greater depth by more experienced practitioners, who can create their own combinations according to their level of awareness. With increasing practice mindfulness is further refined, and more variety is added. Economical practice is also learned in more complex āsanas. Finetuning develops into excellence. The speed at which you perform the exercises as well as how long you hold them can be increased to improve stamina.

These basic exercises are like building blocks for more complex ones. They emphasize a specific area of the body and show in detail how to work according to the principles and reach your aims. Once you have mastered the relevant basic exercises they can be combined into more complex tasks, further developing the aims. This leads towards the classical āsanas. The basic exercises place greater emphasis on mobilizing, stretching, strengthening, and relaxation. Coordination and balance are also practiced in basic exercises, but even more so in the more complex tasks, the āsanas. Synchronization is particularly developed in partner or group work. Synchronizing movements of different parts of the body also plays an important role in āsana practice.

Yoga teachers will also find the basic exercises helpful to lead step by step towards the more complex āsanas.

In summary the basic exercises are modified from classical āsanas:

• teaching important details of the āsanas; the details can be combined and integrated into more complex tasks

• helping to understand the essence of the āsanas

• leading to a mindful, precise exercise approach.

There are many more possibilities to move and correct different areas of the body than can be presented here. Once you have learned and understood some of these exercises you may wish to create variations or design your own exercises according to your patients’ diagnosis and needs.

Most exercises are illustrated with photographs. Some of the fine movements cannot be seen very easily on the pictures, but can be followed from the description.

Frequently used positions and movements

In the exercise instructions we prefer to refer to individual measures like the patient’s foot length or hand width, as body measurements are individual. Knees hip width apart is particularly used for parallel alignment of the thighs: this corresponds to the knees one fist width apart.

For the position of the feet we sometimes use dorsiflexion and plantar flexion (exercise 10.3, Figure 6.194). Dorsiflexion is the movement at the ankle towards the superior surface of the foot. When wearing flat shoes the foot is mainly in dorsiflexion. Plantar flexion is the movement at the ankle towards the sole of the foot: the higher the heels, the more the foot is in plantar flexion. In dorsiflexion the foot has more stability, whereas in plantar flexion it its more vulnerable. Inversion is the movement of the foot inwards (exercise 10.3, Figure 6.195), while eversion is an outwards movement (Figure 6.196), both without rotation at the hip or knee joints (Kingston 2001).

Supination and pronation in the elbow joint are the rotation of the radius on the ulna. Supination is the rotation of the forearm so that the palm is facing forwards, with the thumb outwards, whereas pronation is the rotation of the forearm so that the palm is facing backwards, with the thumb inwards. The joint surfaces of the carpal bones also allow some complex supination and pronation movements (Kingston 2001).

The neutral position is a fundamental position for many exercises. “Lumbar neutral position is midway between full flexion and full extension as brought about by posterior and anterior tilting of the pelvis … the neutral position places minimal stress on the body tissues. Also, because postural alignment is optimal, the neutral position is generally the most effective position from which trunk muscles can work” (Norris 2000, p. 10). In this neutral position the joints and their soft tissues are least stressed. The neutral position must be distinguished from the concept of neutral zone. This is “the zone in which movement occurs at the beginning of the range of motion before any effective resistance is offered from either the muscular system or the spinal column” (Norris 2000, p. 9). The less stable a spinal segment is, the larger the neutral zone.

The concept of the neutral position can be applied to the whole musculoskeletal system. For the neutral lumbopelvic position the neutral zone between the sacrum and the fifth lumbar vertebra is relevant. Feel your way towards it by tilting the pelvis forwards and backwards within the comfortable range. Make the movements smaller and smaller, until you reach the midrange position. When you are lying on your back, this is often the most relaxed position for the abdomen and the lumbar area. Sitting and standing, the neutral position is the basis for the upright position with the minimum stress. In neutral position the spine is stable during all movements, including movements of the legs and arms. It is a good foundation for lifting and lengthening the spine to support the nutrition of the discs and create enough space for the nerve roots. The neutral position will be applied in many of our exercises and āsanas. Depending on the context it is described in different ways, for example tilting or stabilizing the pelvis, lifting from the lower abdomen, or adjusting the costal arches.

Supine means lying on your back. To achieve the optimum neutral, relaxed position you may need support. To support from the bottom, place a rolled blanket or bolster underneath the knees or a chair under the lower legs. To support from the top, put a pillow underneath the neck and head (see Śavāsana, Chapter 7). There are various methods to support lying supine (Lasater 1995). You may need to experiment to find the best for individual patients. To come up from the supine position, stretch your right arm over your head and turn on your right side, with the right arm supporting the head. Bend both knees, keeping your left hand on the floor in front. Stay lying comfortably on this side for a few breaths in a neutral lumbopelvic position. To push yourself up to sitting, set your left leg slightly free from the bent position. If you prefer to finish on the left side, turn onto your left side in the same way. Moshe Feldenkrais has written a very detailed description of this and other transitions between different positions (Feldenkrais 1984).

Prone means lying on your front. As with the supine position, this may need a variety of supports for patient comfort. We are not using this as a relaxation position, rather as a starting and finishing position for some exercises. There are different ways to come up from the prone position. We prefer a gentle method: stretch one arm besides the head, turn on this side and push yourself up to sit as described for coming back from the supine position.

We have described several basic exercises and āsanas sitting on the floor. As sitting on the floor is not suitable for all patients, there are modifications. If the patient cannot sit on a support like a brick or pillow, many of the sitting exercises can be done sitting on a chair or on the treatment couch. If the patient finds it difficult to get up from the floor, it can be helpful to hold onto a chair or table for support.

The knee hug position (exercise 1.4, Figure 6.4) is the starting and finishing position for lumbar mobilizing and abdominal strengthening exercises. It is a relaxing pose on its own.

Four-point kneeling (exercise 1.14, Figure 6.28) and variations is used in several chapters, with different emphasis. Patients may find it comfortable to kneel on a soft support like a folded blanket. This also increases the height of the pelvis so that the back is closer to the horizontal line.

Forward-bent kneeling (exercise 1.9, Figure 6.16) is a suitable position to finish four-point kneeling variations as well as the dog pose. It is a relaxing pose on its own, particularly if performed with props, as shown in exercise 1.9 (Figure 6.16). In addition to the supported relaxation poses we have given a few examples of oscillations. These gentle rhythmic movements are particularly inspiring fluid movements (Lederman 2001). To refine the exercises and sink into deeper relaxation it is important to feel softness in the eyes, ears, palate, tongue, and larynx, and to be receptive and mindful during practice (see Chapter 2).

Many of the exercises get easier and more accessible by using props. The questions of what patients can do and which exercises should be avoided are replaced by the question of how to modify the exercises. We describe important basics for this exercise approach, as this is an important factor in therapeutic exercising. Most of the props we suggest can be found at home. We recommend buying a sticky mat, a foam brick, and a belt (see Chapter 1).

Breathing during exercising

Breathing during exercising should be natural and light. The natural breathing movements and patterns should not be disturbed. In this way it is possible to take deeper breaths in harmony with activity. Some movements, particularly downwards movements and stretches, are frequently done while exhaling. Moving with exhalation helps you to relax in the exercise. Some movements, particularly upwards movements, are frequently done while inhaling. If the movement matches the upwards movement of the side and frontal ribs it is sensible to perform it while inhaling, whereas if it is closer to a downwards movement of the ribs, perform it while exhaling. But this is not a dogma. For some individuals it may be better to coordinate this differently, so it is often useful to play with matching the movements and the breath. In particular very mobile, loose patients may prefer to perform more movements while inhaling. Mindful, attentive practice often gives the best answer. Breathing during exercising should only be through the nose.

1 Basic exercises for the lumbar spine

With reference to the lumbar spine, low-back pain should be mentioned as this is the most common condition for which patients present to manual therapists or start exercising.

As many different pathologies can cause low-back pain, a thorough diagnosis is necessary. Particular caution is necessary if the low-back pain is associated with neurological signs and symptoms, bowel and bladder problems, or the patient has lost weight or is feeling ill. If, after thorough medical investigation, exercise therapy is appropriate, you need to bear in mind the general function of the lumbar spine as a weight-bearing structure that needs to be able to lift against gravity and change direction, in addition to being well balanced. Strengthening and mobilizing exercises are required.

Mobilizing exercises may cause a problem if they reach hypermobile areas instead of restricted ones. We have seen patients’ conditions worsening, particularly after intensive, ambitious practice. In many cases we could see that the hypermobile segments were vulnerable to being overstretched or overmobilized. For these patients two things were helpful:

• easing off slightly from the boundary, the limit of movement

• combining mobilization with muscle strengthening.

Muscle strengthening is performed with only part, about one-third, of full strength and repeated several times. These exercises should be performed within the painfree range.

Mobilization exercises should give a feeling of ease and relaxation. This experience of easy, painfree exercises can help eliminate conditioned pain reactions.

To integrate these abilities into more complex and everyday actions we recommend the balance, coordination, and synchronization exercises. For healthy movement patterns of the lumbar spine a wider context is important, particularly targeting the pelvis, iliosacral joints, and the hips, as well as the feet and knees. The functions in the middle and lower thoracic spine can also influence the lumbar spine. All these connections contribute to a healthy balance of stability and mobility of the lumbar spine. In this way the cooperation between the muscles, the nutrition of the discs, and the nerve roots can improve and be kept at a healthy level. All the bony and soft tissues and fluids can function in a healthy way.

Exercise 1.1 Lumbopelvic stability

Aims: strengthening the lower abdomen, pelvic floor, and lumbar area.

1. Lie on your back with your hips and knees bent, the soles of the feet resting on the floor, the heels one foot length away from the buttocks. Use a pillow for your head if necessary.

2. Gently tilt your pelvis until you find the neutral lumbopelvic position. Maintain this neutral position throughout the following series of exercises.

3. Put your fingertips on the central line of your lower abdomen about 5 fingers below your navel. Keeping your throat and your shoulders relaxed, slightly pull this area of the lower abdomen inwards and towards your lumbar spine as you exhale; feel the slight contraction of the lower abdomen beneath your fingertips. Then inhale normally, keeping your abdomen relaxed.

4. Perform point 3 3–5 times, with 1–2 normal breaths in between if necessary. You may feel the associated activity of the pelvic floor and the lumbar area as well.

5. With an exhalation repeat the contraction, hold it for up to 3 breaths, and release it while exhaling.

6. Relax for a few breaths.

7. Keeping your throat and shoulders relaxed, practice the gentle contracting action of point 3 while inhaling; relax as you exhale; feel the slight contraction with your fingertips on the central line of the lower abdomen.

8. Perform point 7 3–5 times.

9. Again hold the contraction for 3 breaths, and release it while exhaling, hands comfortable.

10. Stay calm for a few breaths; feel the softness in your abdomen and pelvic floor.

Refined work

Resting your arms besides your body on the floor, follow points 2–10 without controlling the lower abdomen with the fingertips.

Exercise 1.2 Abdominal strength

Aims: gentle strengthening of the abdominal muscles, stabilizing the lumbar spine.

1. Lie on your back with your hips and knees bent; rest your head so that your neck is relaxed, if necessary on a pillow; hold the knees close towards the chest so that the back is comfortable on the floor; feel your lumbar area long and broad (Figure 6.1).

2. Without changing the position of your pelvis, lower your right leg as you exhale until the sole of the foot touches the floor (Figure 6.2); you can feel the position of your lower back with your hands, while you lower your leg.

3. Keep the foot on the floor while you inhale; if necessary you can keep it there for 1–2 breaths.

4. With another inhalation bring the leg back to the starting position, without changing the position of the pelvis.

5. Perform points 2–4 3–5 times.

6. Repeat points 2–5 for the left leg.

7. Lower your right leg towards the floor in three sections: breathing out, lower one-third, breathing in, pause; breathing out, lower the second third, breathing in, pause; breathing out, lower the last third, put the foot on the floor, then pause for 1–2 breaths. Control the position of your lower back with your hands.

8. With an inhalation bring the leg back to the starting position.

9. Perform points 7 and 8 twice.

10. Repeat points 7–9 for your left leg.

11. Finish in the knee hug position (Figure 6.4) for a few breaths. Feel the softness in the abdomen and lumbar area.

Figure 6.1

Figure 6.2

2. Keeping the pelvic position stable and the throat and shoulders relaxed, lower both legs as you exhale until the soles of your feet touch the floor. Stay there while you inhale; if necessary wait for 1–2 breaths. If the pelvis starts tilting while you lower your legs, stop and reverse the movement.

3. With another inhalation bring both legs back to the starting position (point 1).

4. Perform points 2 and 3 3–5 times.

5. Lower both legs towards the floor in three sections: breathing out, keep your pelvis stable, lower one third; breathing in, pause, breathing out, keep your pelvis stable and lower the second third; breathing in, pause, breathing out, keep your pelvis stable and lower the last third, feet on the floor; then pause for 1–2 breaths.

6. With an inhalation bring the legs back to the starting position.

7. Perform points 5 and 6 twice.

8. To finish stay in the starting position (point 1) for a few breaths.

Variation b

Lie on your back with your hips and knees bent; hold the knees close towards the chest so that the back rests comfortably on the floor (Figure 6.1). Maintain this contact of the pelvis with the floor throughout the exercise. Practice as described in variation a, except that you move the legs in three sections while lifting them off the floor.

Variation c

Perform the movements described with knees and feet slightly apart; do the exercise 3–5 times, each time slightly changing the distance of the knees and feet, within a sensible range for your hips.

Variation d

1. Lie on your back with your hips and knees bent; hold the knees close towards the chest so that the back rests comfortably on the floor. Maintain this throughout the exercise.

2. Without changing the position of the pelvis lower both legs as you exhale until the soles of your feet touch the floor. Stay there while you inhale; if necessary wait for 1–2 breaths.

3. Maintaining the position of the pelvis slide your heels along the floor away from your hips with another exhalation, until your legs are straight.

4. Inhaling again, slide your heels towards the hips, and bring your legs back to the starting position (point 1).

5. Perform points 2–4 3–5 times.

6. To finish lie on your back with relaxed legs for a few breaths; be aware of the position of the back of your pelvis and your lumbar spine; adjust your abdomen and lumbar area so that they are soft.

Exercise 1.3 Rhythmic relaxation

Aim: gentle mobilization of the lumbar spine.

1. Lie on your back, with your hips and knees bent and the soles of your feet on the floor and the heels one foot length away from the sitting bones.

2. Bring your pelvis into a comfortable, neutral position on the floor.

3. With an exhalation slightly slide away one hip in the direction of the same foot, then the other one, about 3 times during this exhalation, to oscillate the lumbar spine into rhythmic side-bending (Figure 6.3). Finish with your pelvis in symmetry.

4. While breathing in, stay calm.

5. Perform points 3 and 4 3–5 times.

6. Stay relaxed for a few breaths and feel the change in your lumbar spine.

7. Lie on your back with your hips and knees bent; hold the knees close towards the chest so that the back is comfortable on the floor (Figure 6.1).

8. Gently rock your legs from side to side, about 20°, slightly lifting the opposite hip, to oscillate the lumbar spine into rotation, up to 3 times within one exhalation; finish in the starting position (point 7).

9. While breathing in, stay calm and feel the relaxation of your abdomen and lumbar area.

10. Perform points 8 and 9 3–5 times.

11. Stay relaxed for a few breaths in the knee hug position (Figure 6.4).

Figure 6.3

Refined work

Play with the scope and frequency of the oscillation to find the easiest and most comfortable rhythm.

Exercise 1.4 Knee hug rotation variation

Aims: mobilizing the lumbar spine into rotation, balancing the trunk muscles.

1. Start with the knee hug position (Figure 6.4); hold the knees close towards your chest so that the back is comfortable on the floor; holding a brick or pad between your knees may be useful to help position the hips and knees (Figure 6.5).

2. Bring your arms down in line with your shoulder girdle, with the palms facing the ceiling; you may like to also try it with the palms facing the floor, as shown in Figure 6.7, below.

3. Without shifting the knees move your legs to the right side as you exhale; the left hip comes off the floor; the left shoulder and arm should remain on the floor, so only go this far and as long as you can control the rotation (Figure 6.6); keep your head in line with your spine.

4. Hold this position for 1–2 breaths.

5. Bring your legs back to the center as you inhale.

6. Repeat points 3–5 for the left side, keeping the right shoulder and arm on the floor.

7. Perform points 3–6 3–5 times.

8. Relax in the knee hug position (Figure 6.4) for a few breaths; feel the softness in your abdomen.