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A MATTER OF HEALTH Integration of Yoga & Western Medicine for Prevention & Cure Dr. Krishna Raman

Helios Books Co. Private Ltd. No. 4, 13th Avenue, Harrington Road, Chetpet, Chennai - 600 031 www.heliosbooks.com @ 1998 Dr. Krishna Raman ISBN : 978 93 82540 02 1 First Published April, 1998 Reprinted November, 1998 Reprinted 1999 Reprinted January, 2000 Reprinted October, 2000 Reprinted August, 2001 Reprinted April, 2004 Reprinted February, 2006 Second Edition November, 2008 Every effort has been made to keep the subject matter current at the time of publication. But research keeps discovering newer facts and the reader is requested to email the author in case of any query and refer to updates in “Yoga & Medical Science : FAQ” by the same author. No reproduction in any form of this book, in whole or in part (except for brief quotations in critical articles or reviews), may be made without written permission of the author and the publishers. Cover Design : Kamerad-News Advertising Ltd. Photographs : R. Sridhar & Chella Diagrams

Radhika Krishna & reproductions from Bogduk / Twomey, Clinical : Anatomy of theLumbar Spine; Courtesy : Churchill Livingstone, Publishers

Typesetting and Printed at Nagaraj & Co. Pvt. Ltd., 156, Developed Plots Industrial Estate, Perungudi, Chennai - 600 096. Tel : 91 - 044 - 66149291, 66149292. Fax : 91 - 044 - 66149295

Dedication

With humble pranams I offer this work at the Lotus Feet of Bhagavan Sri Sathya Sai Baba.

Acknowledgement

My most profound gratitude is due to my Guru, Yogacharya Sri B.K.S. Iyengar, to whom I owe all my knowledge of yoga.

Sage Patanjali, the Father of Yoga

Yogacharya B.K.S. Iyengar The life and work of Yogacharya B.K.S. Iyengar are of epic proportions. He was born on December 14, 1918 in Bellur, Kolar District, Karnataka, India in a large and poor family. At the early age fifteen, he went to Mysore where he was initiated into yoga by his brother-in-law Prof. T. Krishnamacharya who was a well known scholar and a yoga adept. Though young, Iyengar immersed himself totally in yoga practice, with the result he had to discontinue studies at the matriculation level. In spite of suffering untold pains of tortured nerves and bruised muscles, he gained proficiency in large number of asanas in an incredibly short time. In 1937, Dr. V.B. Gohale, a civil surgeon and a yoga enthusiast, arranged for him to come to Pune and join the Deccan Gymkhana as yoga instructor. In 1948, he taught yoga to J. Krishnamurti, and this association continued for two decades. Krishnamurti described him as The Best Teacher. He earned the title of Yogi Raja from Swami Shivananda of Rishikesh. In 1952, two prominent Indian personalities Jayaprakash Narayanan and Achyutrao Patwardhan became his pupils. In March 1952, the celebrated vionilist Yehudi Menuhin came in contact with Iyengar, when he was on a visit to India. He wanted to introduce him to the West at once, Iyengar was able to visit Europe only after two years. Since then, he made several trips to all corners of the world to promote yoga. His comprehensive book Light on Yoga was published in 1966. This work has been hailed as the Bible of yoga and has been translated into both Indian and foreign languages. The Yoga institute in Pune was established in 1973, and has been named after his wife, Ramamani Iyengar. In 1976, Iyengar gave a memorable lecture-demonstration at the Harvard College, Philadephia. This performance inspired the creation for the monumental sculpture "After Iyengar". It was also acclaimed as an experience that comes rarely in one’s life. The Film and Television Institute of India produced a 22-minute film about him titled Samadhi that won the Silver Lotus Award instituted by the Government of India. His second book Light on Pranayama has been published in ten languages.

In 1982, he participated in the Festival of India at London, at the invitation of the educational department of the United Kingdom. His third book "The Art of Yoga" was published in 1985. In the same year, he was invited by President Jacques Chirac, then major of Paris, for the Festival of India in France. Here the film Guruji was released. In 1987, Timeless Books, U.S.A. released the book Iyengar : His Life and Work. 1988 saw the release of The Tree of Yoga. In 1993 his work Light on Yoga Sutras of Patanjali was released. There are hundreds of Iyengar Yoga Centres imparting training in his method of yoga in all parts of the world including his native India (with centres in Bangalore, Bombay, Delhi, Madras, Dehra Dun, Rishikesh...) U.S.A., U.K., France, Canada, Australia, New Zealand, Ireland, Switzerland, Italy, Spain, Netherlands, Germany, Austria, Denmark, Israel, Morocco, Russia, Ukraine, Uzbekistan, Poland, Republic of Czech and Slovania, Belgium, Sri Lanka, Mauritius, Swaziland, Lestho, Japan, Korea, Argentina, Chile, Mexico, Malaysia, Southern Africa, Kenya and Zimbabwe. His artistic performances have elicited such epithets as Supreme artist, Divine Gymnast and Michaelangelo of Yoga. Titles as Yogi Ratna, Yoganga Shikshaka Chakravarti have been conferred upon him. He received the 1998 Rajotsava Award and the 1990 Patanjali Award of the Government of Karnataka, the All India Vasistha Award in 1991, the Pune’s Pride Gold Medal in 1992, and Gold Medal for outstanding contribution in the field of yoga education from the All India Board of Alternative Medicine. In 1991, he received the Padma Shri Award of the Government of India. He was also admitted as a Fellow of International Council of Ayurveda. The book "Light on Pranayama" in Hindi received the first cash prize of Rs. 5,000/- at the 16th National Prize Competition for published literature on Physical Education, Sports, Yoga and Health. In December 1991, at the 4th Congress of the World Federation of Societies of Holistic Medicine (Italy) he was awarded the Purna Swasthya Award. The Medicine Alternative Institute affiliated to the Open International University for Complementary Medicine which is recognised by the President of Sri Lanka, and the United Nations Charter for the University of Peace awarded him with the degree of Doctor of Science, in December 1991. In January 1992, he was honoured with Shri Krishnanugraha Prashasti Patra by Jagadguru Shri Madhvacharya Mula Matha Mahasthana. In 1995, he was awarded the Punya Bhushan Award and "Gem in Alternative Medicine" by the All India Board of Alternative Medicine. He has been included in the following: 1. Who is Who in the World - 1983 2. Who is Who is Asia 3. Who is Who in India 4. Who is who in Euro-Indo-1995

5. Men of Achievement 6. International Authors, Cambridge, U.K. - 1983 7. Contemporary Authors, Cambridge, U.K. - 1983 8. Prominent Personalities of India, by Institute 9. Biographical Studies, Delhi 10. International Directory of Distinguished Leadership 1997 of the American Biographial Institute.

Dr. B. Ramamurthi Dr. B. Ramamurthi, M.B.B.S., M.S., F.R.C.S. was head of the Department of Neurosurgery and Neurosurgeon, Voluntary Health Services, Madras - 600 113 from 1978 and Neurosurgeon, Government General Hospital, Madras, Professor of Neurosurgery from 1958 to 1978 and Principal, Madras Medical College, 1976 to 1978. His other achievements include :

Contents Introduction Foreword Preface to Second Edition Preface to First Edition Understanding Yoga Section I : Lifestyles Health and Food The Growing Years, the Aged and Yoga Yoga in Professional Life Yoga and Sports The Artist and Yoga Women and Yoga Pregnant Women and Yoga Section II : Functional Anatomy and Physiology Cells and Tissues The Skin The Bony Skeleton Joints Muscles The Cardiovascular System The Haematological System

The Respiratory System The Digestive System The Renal System The Endocrine System The Nervous System The Special Senses The Reproductive Systems Yoga as a Means of Preserving the Body Section III : Exercise, Asanas, Pranayama and Props The Importance of Exercise Asanas Pranayama Props Section IV : Medical Disorders and their Management Yoga as Medicine Cardiovascular Disorders Pulmonary Diseases Gastroenterologic Diseases Metabolic Diseases Neurological Diseases Gynaecological Diseases ENT Diseases Orthopaedic Diseases Need for Extended Work with Therapeutic Yoga Appendix Glossary List of Illustrations Index

Introduction The great science of yoga is India’s unequalled gift to mankind. If mankind is to evolve further, and if it is to save itself from its own aggressive tendencies, the only path open is through the science of yoga. Though the ultimate goal of this science is the realization of the Absolute, in day to day life it is useful and necessary to maintain mental and bodily health. Bodily exercises (asanas), breath control (pranayama) and mind control (dhyana) are all helpful to conquer bodily and mental ills. The role of the mind in the creation of health and ill-health has been well emphasized by ayurvedic physicians. In praising Dhanvanthiri, the first sloka begins by emphasizing that diseases arise in the body due to problems of the mind like raga (excessive desire). The great influence of the mind over the body, its health and functioning, was well understood by our ancients; hence, throughout our glorious history, control of the mind was given prime importance for achieving health of the body, happiness of the mind and harmony with society and the universe. The great Patanjali, who gave us the Yoga Sutras, has been praised as the one who gave us yoga for discipline of the mind, medicines for health of the body and grammar for purity of the tongue (language). The close association of health and yoga has always been emphasized in ayurvedic texts. Apart from medicines, surgical practices and mantras, yoga was an accepted method of treatment in ayurveda. Hence it is appropriate that Dr. Krishna Raman has compiled this synthesis of medicine and yoga. Having studied modern medicine and having had training in yoga under the great master, Sri B.K.S. Iyengar, Dr. Krishna Raman is a fit person to attempt this difficult task and he has done it well. This compendium will be useful to both medical and lay persons. The first section, on Lifestyles, is most appropriate for modern living with its stresses and strains. Health problems of professionals, sportspersons, artists, different age groups and women are well presented and the section provides interesting and useful information. After explaining in simple terms the structure and functions of various parts of the body, the value of yoga in medical disorders is discussed in lucid terms. It was a pleasure to go through this book. It will be found useful by persons of all ages and also by modern medical practitioners who may not know all the nuances of yogic practices. It is heartening to know that in this age of hurry and stress and of emphasis on high technology medicine, there are wellestablished techniques in the science of yoga to restore one’s health and also to contribute to a life of positive health, with happiness and harmony.

Chennai 14th Nov. 1997

Dr. B. Ramamurthi

Foreword I am filled with joy in writing this note about the book, A Matter of Health: Integration of Yoga & Western Medicine for Prevention & Cure by my pupil, Dr. Krishna Raman. A book of this kind, on therapeutic yoga, has been long awaited. Dr. Krishna Raman, a physician who is also well trained in the intricacies of yoga, has convincingly made a case for an alternative approach to the treatment of various diseases afflicting human beings today. His work is a definitive presentation of therapeutic yoga for the promotion of holistic health as well as for prevention of diseases. He has not only discussed the value of yoga as such, but also the efficiency of yogic asanas and pranayama as part of a healing art. While conceding the scope and efficacy of allopathic medicine, the author nevertheless draws our attention to the fact that allopathy has its shortcomings and its side effects are many and debilitating. Though considered good for immediate relief, it often doesn’t go to the root cause of the problem to begin the cure. Dr. Raman has divided his work into an introduction and four sections. In the Introduction, he explains yoga as described by the father of yoga, Sage Patanjali in his Yoga Sutras. In a nutshell, the author explains the teachings of Patanjali, how yogic discipline stills and quietens the mind to experience calmness and serenity as well as silence in general and how asanas and pranayama help man to succeed in this endeavor. He strongly emphasizes that the mind plays a significant role in maintaining and sustaining sound physical health, clarity of thought and spiritual benevolence, if yoga is practiced regularly as a part of one’s daily activities. At the same time he has dealt very effectively with how yoga prevents the onset of diseases. In Section I, Dr. Raman discusses the kinds of food that are beneficial to the body and the body’s need for fats, proteins, carbohydrates, fibers, minerals and vitamins and discusses various life styles — housewife, artist, professional executive and athlete — and points out how anyone, of any age group, can use yogic practices to counteract and prevent the illnesses he or she is particularly susceptible to according to his or her vocation, environment, attitude and aptitude. The chapter on sports is exhaustive. In it the author discusses how yogic asanas can help alleviate the negative repercussions of any sport. I am glad to note that he has devoted a chapter to pregnancy, calling it ‘an amazing wonder of nature’. He explains the immense value of asanas and pranayama for pregnant women, pointing out the ways to avoid complications that can follow pregnancy and how

women can have a safe delivery, free of problems and pain. Section II of the book is on functional anatomy and physiology. Unless we know how our body is fashioned and how it works, we will not be able to understand what can go wrong with it and how best it can be set right. The body is the most complicated machinery, with a superb capacity for adjustment, possessing a powerful mind of its own. Though it is the machine most abused by man, it tries to adapt to the fanciful thoughts of the mind; but it gives way when it can no longer withstand the onslaught of desires and ambitions. He ends this section explaining how the ethical, physical, physiological, mental and intellectual disciplines of yoga help to maintain all the systems in our body to function with harmony and balance. In Section III the importance of yogic exercises and preservation of health is emphasized. One can argue that many people who do not exercise at all still live to a ripe old age. Living is not important, but living in a meaningful way with benevolent health is. It must be a dynamic, electrifying life to be worth living. Yoga, which is akin to nature wherein the five elements of the body are kept in a balanced ratio, keeps at bay the degenerating effects of aging and ill health. As a medical professional, Dr. Krishna Raman considers asanas and pranayama the best tools to maintain health in the cellular system. The arithmetic and geometry of yogic postures guarantee that every part of the body used is invigorated with fresh blood. The deliberate and steady holding of the poses, with their rinsing, squeezing and drying actions, is far superior to hasty, jerky workouts. The author describes various asanas — standing, sitting, forward and backward extensions, inversions, twists, balancing — and explains the effect of each on the muscular, organic and glandular systems. He also shows how the techniques of pranayama (science of the breath) can be used as therapy. In the chapter on props, Dr. Raman demonstrates the use of yoga props that I invented for those patients who are weak or elderly and for those who are unable to practice independently. He demonstrates very clearly the quick results that can be obtained by employing simple equipment. The last section of the book is a discussion of eighteen common medical disorders that particularly lend themselves to yoga therapy. Their causes and symptoms are listed, their medical management is expounded and treatment by yoga, in conjunction with allopathy or on its own, is recommended. The author has shown how excessive and prolonged medication and/or surgery can sometimes be avoided through the practice of asanas and pranayama. The book is richly illustrated with line diagrams and photographs. This is a noteworthy attempt by a physician to use asanas and pranayama for different needs and ailments by using props. The book is the culmination of his research in the field of therapeutic yoga. He has observed and recorded actual changes in his patients after they had practiced yogic asanas as required. I am proud of Dr. Krishna Raman for his scientific approach, meticulous treatment and presentation of the age old science of yoga in an appealing way for the general public. It has been said that East and West can never meet, but Dr Raman has shown through his work that East and West can indeed meet

where knowledge is concerned. In my opinion this book will be invaluable to people exploring alternative approaches to health care. It will also be a great asset to yoga students in general and especially valuable to yoga teachers. If Dr. Krishna Raman’s work is well received, I shall be grateful for having shared in its presentation.

Pune 24th Nov 1997

B.K.S Iyengar

Preface to the Second Edition I thank my readers who are responsible for my bringing out the third edition of this book. So much of research has been done in the field of exercise and health. Many studies confirm what has already been said and newer ones throw light on other issues. The obsession with staying healthy is more than ever before. At the cost of redundancy, it must be remembered that health is not entirely in our hands as our past karma plays a definitive role. We merely do what is needed from the material plane -God’s grace gives us the fruits. Yoga has also become an obsession which is not healthy. The trend in India these days is to use yoga for any situation in life. The request comes for all kind of ailments for which yoga has no role at all. Some of the incredulous claims include curing of myopia, jaundice (believe it or not), growth retardation, thyroid disorders and so on. One can easily see banners citing “effective yoga therapy for all aliments”. There is no point in faulting the claimants for this. Those who seek relief from yoga should educate themselves about their ailment before attempting to understand whether yoga can help. In most situations the seeker is ignorant about the working of the ailment and of the role of yoga. I suggest that those who seek relief from yoga first consult their physician to ascertain whether yoga can help or not before embarking on their yoga practice. This will avoid unnecessary disappointments. When I first wrote this book my perception of the role of yoga as a therapy was different from what it is now. As I have seen clearly the precise place of yoga in relation to clinical ailments, I have no doubt as to when and where it will work. The book has been edited to fall in line with this and I hope it puts my readers in a clear light. The readers are also advised to read my second book Yoga and Medical Science: FAQ which contains in-depth discussion of yoga in relation to medicine (over 450 Q&A). It also contains ultrasound images of several yoga poses that precisely clarify arterial flow patterns. In the field of medicine learning never ceases as each patient teaches us something. More than anything else, we need to be grateful to them for this. Confidence building is the first step in betterment of health and as physicians we should focus on this. This will improve doctor patient relationship too and prevent unnecessary litigations. A relationship of trust is needed between physician and patient. Ultimately let us pray that all living beings in all planes of existence be happySamasta loka sukino bhavantu! Chennai 2nd Nov 2008

Dr. Krishna Raman

Preface to the First Edition The human body and mind are gifts of God: the capital given to us without any interest payable. For anything in life to be fulfilled, the body should be healthy and this needs constant looking after. Just as a car needs constant care, the body and mind need the same. This is best done by regular exercise. Awareness of this is certainly better now than many years ago, but exercise oriented persons still form a minority in our vast world. In today’s fast world, with the easy availability of different types of cuisines, both vegetarian and non vegetarian, junk food, alcohol and cigarettes, and the constant bombarding of our consciousness with advertisement of such foods through different media, we succumb, with resultant health problems. Mental health is a predecessor to physical health. Physical health is possible only through exercise and mental health through regulating our living in every facet of life. Our ancient sages have given us guidelines for mental and physical well being but we rarely follow them. Health can be achieved only if we have a firm commitment to it which lasts all our lives. It may be that sometimes, with the best of care, we may fall ill, but this illness will not damage our bodies in the way it could if we did not take care. Our duty to our body and mind should be done; the rest is left to the higher power. This is the way to health, a commodity so sorely needed today. I began practising yoga at the age of 14. Little did I then realize that yoga would play a major part in my life. Having decided early in my life to join the medical world which brings one close to the inner workings of the human body, I graduated from a conventional western medical school. But all along I realized the need to treat clinical problems as non invasively as possible. To further my own yoga frontier, I studied with the famous Sri B.K.S. Iyengar, the foremost exponent of yoga in the world today. As my Guru, Sri B.K.S. Iyengar has infused me, ever since our first meeting in 1979, with an enormous dynamism and positivism in the field of health which has helped me tremendously to be a physician of a different kind, with a different perception of health and disease. The uniqueness of "Iyengar yoga" The system of yoga taught by Sri B.K.S. Iyengar has popularly come to be known as "Iyengar yoga". There is a distinct difference between this and other systems, which places his teachings far above all else. This is particularly so when one analyses his methods medically. Medically, when the human body is exercised and the internal organs are used along with the external, certain principles have to be followed in order not to injure the body. In most yoga schools, there is no depth to the teaching of yoga, as can be seen if one happens to be a physician. Secondly, this system can be used in mainstream medicine to solve major medical problems where other systems have failed. I have studied different systems and have found that there is a lack of anatomical guidelines in the execution of asanas and pranayama. To illustrate this I will give several examples. In standing poses (Trikonasana, for example), if one

observes students trained in other systems, there is no arithmetical and geometrical perfection and certain areas are ill affected. Again, in Headstand, there is no guideline in other systems on how to prevent pressure on the brain due to the increase in blood flow velocity; whereas, in "Iyengar yoga", one learns to adjust the blood flow in such a way as to obtain the correct effect inside. This can be confirmed by sonographic studies. The frontal and the back brain have to be kept parallel in order to ensure proper and optimum blood flow and relaxation of the neurons of the brain. Unless one practices the different systems, it is difficult to understand this. Generally, yoga is done slowly and with a lot of stretching, but there is no strength in the stretch and contraction is totally forgotten. Moreover, I have seen number of patients consulting me with no relief from other systems and when the protocols are followed relief results very soon. Any exercise has to strengthen, tone up the system and preserve the body as one grows older. To achieve this, the different parameters of the body need to be observed to find out if they are used to the optimum. As a medical professional, I find that only "Iyengar yoga" achieves this. In this system, the body is made robust both outside and inside. A good example is the practice of backbends which provide vitality to the system. In "Iyengar yoga" one insists on a certain geometric shape of the asana, which alone provides cardio-respiratory health; whereas, in other systems, one can observe incorrect shapes and practitioners suffering ill health later on. For example, in Urdhva Dhanurasana, medically, only at a particular angle of the dorsal spine does the heart pump efficiently. This is logical as certain angles compress the heart. The correct angle is taught in the Iyengar system. As far as possible, the skin on the front and back of the body have to be kept parallel to each other. The pelvic girdle should not collapse which then results in compression of the pelvic organs. Whether the geometry of asanas is at all necessary is a concept that is not thought of in other schools of yoga. Subtleties of yogic practice are available only in the Iyengar system. The test of practice is when the practitioner suffers pain or disease, or secures no relief, in spite of practising yoga, and relief results from the moment the correct method is learnt. I suffered severe backaches even though I practised yoga and no school of thought gave me relief. For years I suffered. Stretching the spine in a different way, as taught by Sri Iyengar, immediately provided an immense change. This made me realise that there is much more to yoga than generally understood and my interest was provoked. This cannot be appreciated by lay persons who do not know anatomy. In "Iyengar yoga", instructions are given on how to strengthen tendons, arteries, veins, bones, organs, etc. An obvious example is Sri Iyengar himself. Today, there is no one of his age who can still perform the asanas he did as a child of 14 and one can easily appreciate the vitality in his body the moment he demonstrates the asanas. I am sure any medical professional who has observed his demonstration can vouch for this. In "Iyengar yoga", the mind is brought to focus on different areas of the body for correct adjustment. In other systems, breathing is taught instead and this is medically harmful. In the practice of asanas, until the lungs can expand perfectly, normal breathing should be observed. This is a vital medical tenet. It is also mentioned in the Yoga Sutras that, unless mastery in an asana is reached, breathing should not be done. This is ignored by all other schools of yoga. In a beginner, the breath is shaky and when asanas are practised with shaky breathing ill health results. In "Iyengar yoga", breathing in an asana is taken from the superficial to the subterranean plane to ventilate the cells of the body and this is

achieved only if the relevant areas can open up to the breath. This means proper performance of asanas. In the Hatha Yoga Pradipika, it is said that the mind is the king of the senses and breath is the king of the mind; calm the breath and the mind is quiet (though reverse is also true). This should be carefully followed. When one medically examines persons trained in other schools, their body parameters lag far behind students trained in the Iyengar system. The body has to be kept dynamic and yet relaxed. In the Iyengar system, the performance of asanas creates a certain "space" between the spindles of the nerves and skin, resulting in profound neurological relaxation. This happens only if every part of the body is put to use. I have already discussed about the standing and inverted poses. In forward bends, if the diaphragm is not kept parallel to the floor, the heart is compressed. If the anterio-posterior diameter is altered the thoracic organs are pressurised. This is taught only in the Iyengar system. In twisting poses, the inner and outer spine have to be kept in alignment, else the spine is not used symmetrically. The chest shape should be similar to Tadasana. In balancing poses, the mind should be kept calm, which means the front and back portions of the body have to be kept like the scales of a balance and one should distribute the body weight in such a way that the pose is arithmetically balanced. In symmetrical and asymmetrical poses like Bakasana and Eka pada Bakasana, one has to really locate the centre of gravity for the mind to be relaxed. Balancing poses therefore mean a balanced action of the body and mind in an asana and not a pose full of tension. Similarly, there are many features of each pose which have to be followed for perfect safety in practice. Then, as Patanjali says, stira sukham asanam ("the posture is pleasant, comfortable and easy"). The aim of yoga is sammatwam yoga uchathe — yoga should bring to the body and mind an even functioning of the physical, mental, emotional and psychological parts of our being. The asanas and pranayama should be practised to provide a perfect balance between the cells of the body. This is integrated yogic practice. At Sri Iyengar’s institute I observed objectively, as a clinician might, many serious medical disorders forsaken by western medicine either during or after treatment by its methods, securing great relief with yoga. Moreover, Sri Iyengar’s methods were radically different from those of any other yoga school I had seen. It seemed more like a laboratory. Slowly I understood the need for practising yoga scientifically, both for healthy people and for patients, and my sojourn in the field of yoga began. Though Sri Iyengar is not a physician, his understanding of the human body is intricate. I owe all my knowledge of the intricacies of yoga and the human body and its relation to medical science to my guru. As an intern trained by Prof K.V. Thiruvengadam, doyen in the field of internal medicine, my interest in applying this science of yoga to my patients was stimulated. I have used yoga for disorders in medicine I would never have believed treatable by western medicine or, for that matter, treatable at all. I studied and researched Guruji’s methods, and found enormous clinical changes in my patients. Much work remains to be done as yoga has to be introduced into mainstream medicine in both ward and school. In this book I have tried to explain in as simple terms as possible human anatomy to the extent known today with our sophisticated gadgetry and the science of yoga. I have also explained several

important and common medical disorders and their treatment, according to both western medicine and yoga. At the end of this, the reader can understand the tremendous need for inculcating yoga into daily life, and how it can be effectively used, with western medicine or alone as a primary modality of therapy if need be. If in the process of all this, dear reader, the truth of what is said is realised, then you and I have been in true communion. I express here my gratitude to all those who have helped me with this work. To Mr. T.S. Santhanam, Chairman, Sundaram Finance, for his kind and generous financial support for the production of the book. To Prof. K.V. Thiruvengadam who taught me all I know in western medicine and particularly the right approach to analysing a health problem, and the only person who taught me to enjoy the deeper realms of medicine, making it a joy. To Dr. S. Suresh and his wife Dr. Indirani of Mediscan Systems, Madras, India, and their team, for patiently helping me to study many vascular flow patterns and organ adjustments in different asanas; for his patience in studying echo and ultrasound changes in odd positions never used in medicine, as in head stand, twisting poses, etc! To Ms. Deepika Rajagopal for her kind willingness to pose for the photographs in the section on pregnancy. To Mr. S.R. Balachander for typing my manuscript. To Mr. Sridhar and Mr. Chella for patiently photographing my poses. To Mr. Chelliah, for providing accurately designed props for use. Mr. Chelliah designed my guru’s props to the right size, often without written measurements. To Dr. C.R. Sundaram for allowing access to the yoga sutras from the library in Sanskrit College. To Dr. Pramila Gurumurty for helping me to access books on music. To my parents, who set an example of how a person should live and shape oneself. To my sister, from whom I learnt not to be fanatical on any subject. To my brother-in-law, in interacting with whom I learnt to have a rational approach to metaphysical science. To my wife who painstakingly drew the anatomical diagrams and patiently bore my constant impatience to finish the work in a very short period and helped me at every stage of the book. To everyone who is devoted to yoga.

Chennai 4th Jan 1998

Krishna Raman

Understanding Yoga Yoga is primarily a philosophical science, born out of man’s seeking to fathom the meaning of existence. Patanjali has said in the second sutra: “Yogah cittavrtti nirodhah” (yogah = integration of all levels of our being; citta = consciousness; vrtti = fluctuation or state of mind; nirodhah = restraint) meaning, “Yoga is the cessation of consciousness.” (Iyengar, B K S, Light on the Yoga Sutras of Patanjali, Indus, New Delhi, 1993. “Samadhi Pada”, I.2.) The ultimate aim of yoga is selfevolution. In ancient times, when people lived the yogic way, good health was a by-product of their daily lifestyle. But, as health deteriorated due to man’s changing values in life, yoga gained ground in its use as therapy. Patanjali has explained that “uncertain action, giving rise to violence, whether done directly or indirectly, or condoned, is caused by greed, anger, or delusion in different degrees. This causes endless pain and ignorance. Through introspection comes an end to pain and ignorance.” (Iyengar, op.cit., “Sadhana Pada”, II.34.) This sutra explains the essence of the genesis of ill health in today’s world and also the method of management. Diseases are due not just due to physical reasons but decay in moral standards also. So curative methods, too, should not be confined to the material plane alone. Yoga is a form of medicine. The fact that it can prevent and cure many ailments has been accepted. Therefore, it should not be viewed as an alternative system of medicine but as a primary form in those areas in which yoga alone is needed to cure ill health. That it can tackle many major illnesses noninvasively puts yoga in a different dimension from just being a stress-relieving panacea. Modern medicine uses bio-feedback as a stress-relieving technique, but yoga works on the inner senses and mind as a conscious process and is thus more direct in its approach. It is an automatic feedback system. Yoga has been used as a tool of psychological and spiritual evolution and health for hundreds of years. It is the only system of medicine that has stood this test of time without any modification. Modern medicine undergoes so much change. Theories alter every minute. Terminologies are modified with each national or international conference. Newer drugs are being discovered to tackle old and new illnesses, old illnesses are vanishing and new ones taking their place. Through all this yoga has remained steady, without change, as the path has been totally researched and laid down by our ancient seers. Unlike medicine, yoga has never changed its theories in relation to

health and disease. It has given clear-cut guidelines both for prevention and cure. Today when, in despair at the failure of Western medicine to deliver, we are turning to natural remedies, yoga is coming into its own. The ancients said that the mind is the cause of all diseases, physiological or mental. Modern medicine has corroborated this with the word ‘psychosomatic’.There is clear proof that mental stress produces many diseases — coronary and respiratory illness, peptic ulcers, weak immune systems. Mental stress is due to disorganized behavior inside the psyche. The soma or body is influenced by the sense organs (which are the agents of the mind). On coming into contact with a pleasurable situation or object — for example, a cigarette — the mind receives a feedback. The organs of action pursue the same object to perpetuate the experience. Thus, the mind and senses are caught in a vicious cycle — each reinforcing the other, being themselves reinforced by the experience. Patanjali has emphasized that “the cause of pain lies in the identification of the seer with the seen, and the remedy lies in the disassociation” (Iyengar, op.cit., “Sadhana Pada”, II.17). If the mind is silenced by the practice of asanas and pranayama and the senses are quietened, perception is altered, leading to a sense of detachment in observation. The senses are not stimulated. The person uses innate intelligence to remain unaffected by pleasurable situations. In other words, realizing the transient nature of everything, he or she is equanimous in all situations. The relation between the psyche and soma is harmonized by the practice of yoga. Drugs may cure illnesses, but the basic inner foundation for achieving health, the harmonization of the inner psyche, is not established. Yoga is of utmost value in this. It is impossible for medicine to attest to many of the benefits of yoga, as the mechanisms are at very subtle levels. Moreover, the concepts of treatment are different from those of medicine. Sometimes, the medical profession, having been tuned to a particular way of approaching the human body, find it difficult to accept other systems of treatment. It is a fact that the human mind is the source of immense energy. We use only one-tenth of our brain cells, the remainder being inactive. In a yogi, with accomplished capacity for supernormal healing, it is postulated that a larger portion of the brain is active. Yogis have demonstrated their healing powers time and again; but this cannot be as objectively studied as medicine would like it to be. There are no medical gadgets to measure many of the effects of asanas and pranayama. There is no way of studying the working of the mind in the material plane. Mind is energy, and energy can heal or destroy, depending on the proper balance in and around us. Life is attributable to a basic energy status in all living things. This energy balance is disturbed in many illnesses. Drugs alone do not cure illnesses; the inner strength of the body also aids it. If this fails, in spite of supreme effort by medicine, the patient can die. It has been shown that the human will is a considerable force in overcoming many illnesses. Beyond this, medicine refrains from commenting. But, yogic science has explored this and has realized that it is possible to achieve a state of mind over matter. A simple example is the ability to shut off pain. It is possible to avoid experiencing severe pain physically by intensely repositioning the mind in a different direction. In this respect, yogis have always demonstrated the supreme capacity of mind over matter. A telling example is that of the very

famous sage, Sri Ramana Maharishi of Tamilnadu in India. When sarcoma was diagnosed, and an operation was imminent, he refused an anesthetic and felt no pain at all. The yogis had precise concepts which were ratified by their methods of treatment. For example, according to the Yoga Upanishad, there are ten vital principles that have specific functions in the body. According to yoga a dyspepsia problem is governed by vital principles known as the apana and naga. The former regulates build-up of air in the gastro-intestinal tract and the latter governs the act of belching. Asanas like twisting poses, forward and back bends, regulate the vital principles in the abdominal organs. When the patient practises twisting poses, the problem of excessive wind formation and belching is controlled. This is due to the regulation of the mechanisms that govern the orderly functioning of the cells. Obviously, such situations have to be experienced and cannot be explained by theory. I have often noticed that doctors are disinclined to accept drugs or surgery for their own chronic conditions as they know the limitations of ‘symptomatic therapy’. They would much prefer a permanent solution. Like yoga. Typical examples are low back pain and essential hypertension, where the role of drugs is limited if yoga therapy is begun early. Considering a problem of essential hypertension, only the elevated blood pressure is neutralized by drugs. The exact cause for the malfunction is untouched. Of course, the general advice to ‘reduce stress’ is doled out. To reduce stress is easier said than done. Yoga, on the other hand, boosts and strengthens the enormous inner defensive energy to control the offensive forces. Now, if such an alternative method — non-invasive, non-drugging — to normalize the pressure is offered, medical practitioners will, I am sure, jump at it. Yoga uses postures to correct inner malfunction according to natural principles. It is important to minimize the use of drugs whenever possible and employ natural methods which, in the long run, preserve the sensitivity of the body. Such a body will be more responsive to treatment than one that has been constantly exposed to medication. Take the case of recurrent sore throats in children. Often, repeated doses of antibiotics are prescribed. Yet, the infection recurs. Sarvangasana and half Halasana are very useful in such cases. Patanjali has said that the disease process can be “dormant, attenuated, interrupted, or fully active” (Iyengar, op.cit., “Sadhana Pada”, II.4). Yoga treats diseases using the process in reverse — the active disease is first made interrupted, then attenuated, and then made to disappear after passing through the stage of dormancy. The yogic approach is step by step, and is never in a hurry. It works along the principles of evolution of a disease.

Yoga as a diagnostic tool Yoga is a useful tool in diagnosing many problems in clinical medicine. Yoga has its own logistics in this. Medicine, too, trains us to look for certain signs in the patient, both on the surface and internally. The investigations are correlated with the clinical diagnosis. Bio-medical engineering has produced a vast array of diagnostic tools that are used for accurate and fast investigations. Unfortunately, we tend to rely more and more on them, often unnecessarily (not considering that its often expensive). Our

innate skills and intelligence in diagnosis are often lost in the process. It is important that a right balance is maintained for, as an eminent doctor has put it: “With all our varied instruments, useful as they are, nothing can replace the watchful eye, the alert ear, the tactful finger and the logical mind.” A study of the ancient texts of yoga and ayurveda gives a totally different approach to clinical problems. It would be excellent if a modern physician is trained in the art of medicine and yoga by which the best of both can be offered to the patient. As stated before, both yoga and medicine have excellent clinical techniques to diagnose ailments. The difference is in the subtlety of perception. In the Darsanopanishad, it is said that the body will be only 96 digits in height. In the Trishaki Upanishad, it is said that there is a vital body in the physical, of no more than 12 digit length. It is said that he is the knower of all in whom this vital body is in equilibrium. It is said that in the middle of the body is the seat of fire. The nadi (meaning nerve, blood vessels or a path), situated in the middle, is the susumna. Around this are 72,000 nadis and 14 of these are important (refer chapter on anatomy of nervous system). Around these flow 10 vital airs. It is said that all these nerves have to be purified for perfect health, and asanas and pranayama have been prescribed for this purpose. The Varahopanishad says that the body is made up of five elements — what is hard is earthy, what is fluid is of water, vital warmth is of fire, motion is of air, ether is the entire body. According to the texts, the number of times a person breathes in a day is 21,600. They elaborate that when the earth region wastes, wrinkles appear; with the watery region wasting away, hairs become grey; with the wasting of the fiery element, hunger and grace of form fade; with wastage of air, tremors appear; with that of ether, life ceases. Hence, to maintain a healthy life, the elements should be attended to. It is well known that there is a vital force in our body which science is unable to explain. The Varahopanishad says that by the practice of yoga the vital airs are nourished, then vital warmth increases. Consequently food is easily digested with healthy production of chyle. By this, the humours of the body grow, which increases knowledge. More of this is being explored and understood by modern science. The ancients did not use any tools to discover what they preached except that of intuition. Yet we find that more and more of their concepts are tenable. The Darsanopanishad says that he who has conquered posture is master of the three worlds. For us, it will be useful if we can interpret it in terms of conquest of mind, body and spirit. This means total health in medical terms. Before we understand health, diseases should be identified and eliminated. Yoga identifies diseases at the embryonic stage, several years before they manifest. A simple example is that of low back pain. Medicine has no method to predict those prone to back ailments. Yoga analyses a person in terms of the ability to perform certain postures, and predicts the probability of the person suffering from low back pain in the future. It is difficult to understand this further unless one has practiced yoga for many years. No doubt medical professionals understand anatomy and physiology, but there is more to be learnt. The parameters that yoga fixes for a fertile breeding ground for ailments in the body are different from western medicine. Another example is that of a person sitting in a chair, with the spine doubled up and with the rib cage

compressed. Medicine does understand that such persons will suffer back pain (as yoga does). Yoga also states that because the heart and major blood vessels are compressed in such a posture, healthy and pure blood cannot flow into the muscles of the heart itself. Just as sitting in a chair for prolonged periods will reduce blood supply to the pressure points, the inner organs also suffer the same fate if the posture is incorrect, says yoga. Sure enough, all these can be proved by diagnostic tests. Many such examples can be given. In my experience, a blend of yoga and medicine is the best. Western medicine and its investigational facilities help diagnosis; treatment can be either by yoga or medicine or both, depending on the ailment. I have, in the later chapters, talked about the mechanism of asanas and a range of diseases wherein yoga finds application. In earlier years, the world of medicine was skeptical about yoga. It was viewed as an esoteric subject, practised by a few. Later, with the advent of Transcendental Meditation in the West, yoga became popular as a stress-relieving technique. In the last few decades, due to the pioneering efforts of Mr. B K S Iyengar, yoga has gained respectability as a therapy.

Yoga — an asset for preventive care Today, more than ever, the need for preventive systems of medicine is being widely realized. The cost of medical care is rising all over the world. Sophisticated diagnostic tools, now thought to be so necessary to assess even simple illnesses, are expensive to manufacture. Prescriptive drugs come in complicated combinations that add to the costs of production. The days of the family doctor, the general practitioner who looked after all the members of a family, are fast giving place to times of specialization, a consultant for every part of the body. Newer and more hi-tech hospitals and nursing homes are being set up. All these cost money, and lead to the impression that doctors are furthering their own interests at the expense of patients. For, finally, it is the patient who foots the bill. Preventive care is the only way by which this urgent problem can be effectively tackled. There are many public health measures which have been introduced to prevent disease. Some of them, like the eradication of plague and small pox, have proved successful. Health education for the masses has clearly demonstrated that clean surroundings, boiled water, childhood immunizations, family planning all have their place in preventing infectious diseases. Early and regular screening for diseases like tuberculosis and cancer has been useful in diagnosis and treatment. Much propaganda has been done against the evils of alcohol, nicotine, drugs and permissive sexual habits. Yet, all this has not been enough. Illnesses are on the rise. Dreaded ones like AIDS have cropped up. We are in this unenviable situation because the individual has not shown enough discipline to focus on health care. This is where yoga comes in. Patanjali’s sutras lay the foundation for a healthy life. That the mind is the root of most physical problems is brought out and guidelines for healthy living are given. The Yoga Vasishta points out that the course of events or destiny is according to thought. “Whatever thought has commenced, in whichever manner, that is established in that manner alone.” (Samvid, The Vision and the Way of Vasishta, Indian Heritage Trust, Madras, 1993, verse 684) For example, though it has been proved that smoking is injurious to health, the manufacture and consumption of cigarettes have not stopped. The body does not need nicotine, only the mind does.

Yoga lays great emphasis on asanas and pranayama to prevent illness and, more important, to preserve health. A regular routine of physical exercises, from a young age, has been shown to be of preventive value in many medical disorders like coronary, respiratory and orthopedic problems. Any kind of exercise is good, but yoga is the ideal form as it is totally non-invasive, gentle and soothing. Also, it is the most cost effective. There is no equipment needed, and even the props recommended for some patients are not expensive. The practice of yoga instills confidence in a person, especially if recovering from an illness. Yoga is particularly valuable as one grows older. As most ailments are degenerative in nature, asanas keep the geriatric person active and therefore, healthy. Apart from the asanas and pranayama, the other precepts for good living laid down by Patanjali reinforce a healthy body and mind. Gandhiji said: “Health is wealth, and the basic requisite for every kind of happiness.” The World Health Organisation has defined health as “a state of complete physical, mental and social wellbeing, and not merely an absence of disease or infirmity”. It is obvious that yoga, which so amply fulfils the criteria for a system of health care, has come to stay.

Patanjali’s Yoga Sutras We owe our knowledge of yoga to the teachings of Patanjali. The word yoga is derived from the root yuj, which means to bind or yoke. It also means to apply oneself to, or direct one’s concentration upon. Yoga is the removal of the imperfection in us to allow purity to shine forth. In short, it is communion with our inner selves. Yoga elevates man from the lowest to the highest level of human existence. Yoga is life itself. It is the most humane subject, encompassing science, art, religion and philosophy. Yoga has been codified by Patanjali into his classic work, the Yoga Sutras, which contains 196 terse aphorisms. The entire life of man is contained in these, provided we know how to interpret them in our daily life. The Kathopanishad says: “When the senses are stilled, the mind is at rest, and the intellect does not waver, the wise say that the state of yoga has been reached.” Patanjali lived in India, around 300 BC. It is said that he was an incarnation of Adisesa, the serpent protecting Lord Vishnu. He was born to a tapasvini by name Gonica. While she was offering oblation to Surya, the Sun God, a small snake appeared in her hands and took human form. It prayed to Gonica to accept him as her son, which she did, naming him Patanjali. (Pata means fallen and anjali means prayer. The method of birth explains Patanjali’s name.) Patanjali was the author of classics in three important fields. He wrote a treatise on grammar, the Mahabhasya. He was the author of a major work on ayurveda, the holistic Indian system of natural medicine comprising medicine, surgery, personal, social and environmental hygiene, as well as psychological and spiritual health. More interestingly, he compiled the Yoga Sutras. The word sutra means a thread. Says Alistair Shearer in his translation of the Yoga Sutras: “Each sutra resembles a knot of the finest thread that must be teased and unraveled, so that every inch of its meaning is displayed. Only then can the whole fabric of the teaching be woven together.”

Patanjali’s 196 aphorisms, divided into four sections, are of extreme brevity, each self-contained in its teaching, yet part of the greater whole. They are: (i) Samadhi Pada, on contemplation; (ii) Sadhana Pada, on the practice of yoga; (iii) Vibhuti Pada, on properties and powers in the yogic path; and (iv) Kaivalya Pada, on freedom and liberation. The first chapter relates to a discussion on dharma and its needs. Dharma is that which sustains and lifts up a fallen person. The goal of any dharmic law is liberation. Patanjali speaks of this in detail as the eight-fold path of yoga, which I shall briefly summarize below. An understanding of this is necessary for readers to get the best out of my book.

The eight limbs Patanjali calls his advice ‘ashtanga yoga’, or the eight limbs of yoga. These are steps towards the goal, not sequential but fully interrelated, each reinforcing the other. Patanjali has significantly described them as limbs because, in any human body, the limbs grow in an organic, proportionate and concurrent manner till full development is reached. The disciplines are yama (moral commandments), niyama (observances of conduct), asana (posture), pranayama (breathing exercises), pratyahara (withdrawal of the senses), dharana (concentration), dhyana (meditation) and samadhi (the settled mind or total absorption). Yama The yamas are five universal laws. • Ahimsa or non-violence extends way beyond its usual physical connotation. True non-violence, which is really freedom from fear and anger, is an inner state of quietude, producing pure, unprejudiced action. • Satya is truth in thought, word and deed. • Asteya means ‘not stealing’ which, in a wider sense, is not claiming anything that does not belong to us. To put it differently, we, as fully evolved spiritual selves, should not hanker after mundane objects. • Brahmacharya is again misunderstood as just physical celibacy. It is more than that: it is the transcendence of all desires, thus leading to an enormous store of energy that has not been dissipated. • Aparigraha is living in a state of non-attachment, without coveting anything. As Shankaracharya points out, it is a difficult achievement: “The body has become old, the sight feeble, the bones weak, the flesh weak, the spirit dull, but man still does not leave his bundle of desires.” Niyama The niyamas are rules for living, also five in number.

• Saucha is cleanliness or purity: both physical, to maintain the body and mind at their optimum best, and spiritual, to achieve a simple and unsullied awareness. • Santosa is contentment. The contented person knows what he wants and how to achieve it and, therefore, is undisturbed by internal and external factors. • Tapas means blaze or fire. It is the burning commitment or desire to reach the pristine state. It is often described as the purification of desires by self-discipline and austerity. • Swadhyaya is the study of oneself, not in any narrow narcissistic manner, but as being conducive to reaching one’s inner spiritual being. • Ishwarapranidhana is total, unconditional devotion and surrender to a higher infinite power. Sri Aurobindo says: “The manifestation of the higher forces takes place only if there is total humility and surrender.” Asana Asana is construed as “posture” by most people. However, asanas are not just a set of exercises or positioning of the body. They are the complete relaxation of the cells of the brain and activation of the cells of the bodily organs. It takes years of sustained effort to master asanas with the concentration and balance needed to make the mind razor sharp. Once asanas have been perfected, being becomes effortless and the yogi loses himself in the pose. Pranayama Prana means all forms of energy — cosmic energy, mental energy, sexual energy and physical energy. It is loosely translated as breath. Ayama is control; so, pranayama is control or discipline of breathing. If the breath is controlled and calm, the senses are stilled and the mind is settled (to reiterate, the converse is also true). Pranayama raises the practitioner to that state of silence rarely experienced in normal, everyday life. Pratyahara Pratyahara, the withdrawal of the senses, is the link between yama, niyama, asana and pranayama and the last three steps — dharana, dhyana and samadhi. Following the rules of living, and practising asanas and pranayama, the yogi is able to turn his senses inward and achieve complete quietude. He is now ready for the ultimate in yoga. Dharana Dharana is ‘one-pointedness’, the state of total absorption. The longer the mind remains in this state of focus, the more powerful it becomes. Dhyana Dhyana is the stage of meditation, the culmination of uninterrupted concentration. The meditative mind

lives in the eternal present, in a state of constant integrated awareness (CIA) and sureness with no ambiguities. Samadhi Samadhi is the peak of yogic achievement, a true sense of communion and peace. This settling of the mind is the heart of yoga, where the senses have been transcended by complete refinement of the body and mind. Let us now briefly examine each of the four sections of the Yoga Sutras. Samadhi Pada The first chapter starts off with the sutra, atha yoga anusasanam (“now the discipline of yoga is explained”). Without following the rules, yoga cannot be achieved. Restraining the fluctuations of consciousness is the aim of yoga. Without this, samadhi cannot be reached. This is to highlight the right path to already evolved souls and help them towards the final goal. For the majority, it serves as a lamp to draw us into the path. Patanjali describes the various fluctuations in the consciousness and the methods by which they can be stilled. All the three gunas (basic qualities of man), namely, sattva, rajas and tamas, have to be transcended. The yogi’s actions are wholly pure, and never a mixture of purity and impurity as our actions usually are. Freedom, says Patanjali, can be experienced only by dedication to this path and patience and trust in God. Abhyasa (practice) and vairagya (renunciation of things that have to be avoided) are like the two wings of a bird. Both require intelligence, not blind coercion. According to Patanjali, once the citta is restrained, the seer dwells in his own splendor. He says that at other times the seer identifies with the consciousness. The movements of consciousness can be painful or non-painful, cognizable or noncognizable. All these we experience in our everyday life. They are controlled by will power. Even the greatest yogi can be in misery if he is not careful. Again, these modifications in consciousness depend on correct knowledge, illusion, imagination, and knowledge based on sleep and memory. Intelligence is also of five types — ignorant, scattered, intense, agitated and restrained. Patanjali talks of correct knowledge, imagination and sleep which he describes as the non-deliberate absence of thought waves. In yoga, what is non-deliberate is made deliberate. Asanas, for example, are a form of conscious sleep. Patanjali defines memory as a collection of experiences. He says that practice and renunciation are the methods to still the fluctuations in the consciousness. Renunciation means freedom from desires. According to Patanjali, this helps develop four states — self-analysis, synthesis, bliss and the experience of pure being. This can be understood in the practice of asanas where the start is one of analysis; then, in the synthesizing stage, the asanas are well understood; then we feel the joy of such asana practice; and finally, there is no asana or practitioner in terms of dualities. We are that asana. We have blended into the posture; there is perfect coordination between body and mind. Patanjali says that practice must be with vigor, trust, keen attention and memory — and for people

who practice thus, the goal is near. To ward off obstacles in the path — physical (disease), mental (doubt, pride, carelessness), intellectual (delusion), spiritual (poor perseverance and maintenance) — Patanjali describes various methods of developing the consciousness, like contemplating a luminous light, the company of enlightened souls, the recollection of previous experiences, the practice of external retention, the cultivation of friendliness and compassion. By mastery over these, the sadhaka gains right illumination which is different from book learning, inference or testimony. A different person is at work thereafter, and is an enlightened being. Sadhana Pada Sadhana means practice. This passage is meant for both the beginner in the spiritual path and the evolved. Patanjali outlines methods towards achieving the spiritual goal. The importance of abhyasa and vairagya are dealt with. The very first sutra in this chapter tells us: “Tapassvadhyaya Ishwarapranidhananai kriyayogah.” (“Having tapas and being engaged in self-study, the sadhaka surrenders to the lord.”) Surrender is the most difficult of virtues. True surrender accepts all in life as the grace of God. This chapter deals with the methods for refining the body, mind and senses. Kriyayoga or the yoga of action has three levels. These are the last three levels of niyama: tapas, swadhyaya and Ishwarapranidhana. I have already discussed what each of these means. These three acts help overcome all obstacles to reach samadhi. Patanjali says that five afflictions (klesa) disturb the mental state. They are avidya (ignorance), asmita (pride or ego), raga (attachment, passion, desire), dvesa (hatred) and abhinivesa (love of life, fear of death, tendency towards attachment). In the state of avidya, life is awful as pain and sorrow are frequent. When desires are satisfied, attachment (raga) becomes stronger. Then follows the desire to live forever (abhinivesa). In the process, the ego is fed and gets inflated due to ignorance. Actions done in such an ignorant state are impure. They bind us and we suffer the effects. Patanjali recommends the practice of meditation to attain liberation and ward off these afflictions. The seat of logic is the front brain, that of reasoning the back brain, that of pain and pleasure is in the base of the brain, and the seat of the ‘I’ is in the upper portion of the brain. It seems that Patanjali was also a fine medical professional in his thinking. Not learning to differentiate between the seer and the seen, man faces sorrow. In order to understand this, let us study what happens in our mind when identifying a simple object, say a tree. The moment we see the tree, memory springs forth and tells us ‘this is a tree’ and we turn away. In other words, our reaction is a conditioned response. No doubt it is important to label, to identify, but in the process we never actually ‘see’ the tree. We are too rapid in our reactions. There is no steady serenity in our observation. We fail to take delight in the tree in all its glory and dismiss it as a mundane object. The English poet, Blake, confirms Patanjali’s teaching in his comment: “The fool sees not the same tree the wise man sees.”

In order to ward off all this, meditation is essential. The seed of future liberation or suffering is in our present actions. Today, science labels this as preventive medicine; but yoga has for centuries been a preventive science and art, both for the body and the mind. Asanas and pranayama protect the body. Meditation and right action protect us from the law of cause and effect: karma. Patanjali says that nature, the three gunas, the senses and organs of perception and action exist either for enjoyment or emancipation. The realization that the seer is the seen removes all false perception and prevents pain. The unbroken flow of right discriminating awareness will bring forth seven states of knowledge. Let us first examine the seven states of ignorance: (i) meanness, feebleness, smallness; (ii) fickleness; (iii) living with misery; (iv)living with association of pain; (v) excessive body consciousness; (vi) self-created conditions for misery; and (vii) no belief in realization. The seven states of wisdom are: (i) right knowledge; (ii) seeing the false as false; (iii) right attainment; (iv) right action; (v) reaching the right goal; (vi) becoming a gunatita; and (vii) achieving liberation. Another manner of perceiving these is: (i) thorough knowledge of the body; (ii) thorough understanding of energy; (iii) understanding the mind; (iv)steady will; (v) right awareness; (vi) awareness of good aesthetic values; and (vii) realization that we are part of the divine. Through dedicated practice one gains an uninterrupted flow of awareness and impurities are destroyed. The yamas and niyamas together with asana and pranayama, interdependent on one another, help the sadhaka in what is called sadhana. Here Patanjali says: “Vitarkabhadane prati-paksa bhavanam”. When there are negative feelings like doubt, pain, grief and suffering, the opposite feelings should be consciously cultivated. Extending this to the physical practice of asanas, Patanjali’s advice can also be construed to tracing pain occurring while in a particular asana to its source and then taking corrective action. Patanjali states that the physical postures ought to be comfortable and easy. This means perfect mastery. This does not mean one can merely sit in some easy posture but that all asanas must be mastered. Only when the asanas are done without effort does poise descend. There is peace in the cells of the body. There is perfect peace and poise in the sadhaka that cannot be disturbed. Then, says Patanjali, and only then, should practice of pranayama be attempted. Prana is an autoenergizing force. Prana and citta are in constant association with each other. As prana is autoenergizing, it generates more power through the practice of pranayama. The energy drawn in by pranayama is stored in the chakras or vital nerve centers. In the third chapter of Hatha Yoga Pradipika, Swatmarama says that as long as the breath is still the citta is also still and there is no fluctuation in the system. The practice of pranayama, apart from having physiological effects, also has spiritual effects (to a degree). When we are agitated, the breath is fast and harsh. If the breath is calm the mind is also calm. Pranayama is a very effective aid, in the beginning, towards realisation of the self. When the breath is restrained, the mind and the organs of perception withdraw. This takes the sadhaka towards the seer.

This is pratyahara. As the mind is silent, intelligence can act. The process then becomes automatic and the sadhaka no longer has to struggle against the pull of memory. Vibhuti Pada In this section, Patanjali speaks of the properties of yoga and the art of integration through concentration, meditation and absorption. The manifestation of supernatural powers is discussed. All this can be rationally understood if we concede the fact that the human brain can achieve anything. One will understand this when we study the life of Bhagawan Sri Sathya Sai Baba. Sri Aurobindo always maintained that nothing was impossible in the realm of spirituality. Patanjali cautions us that the siddhis or powers are not the aim of yoga, though they come to the sadhaka in the course of his quest. The chapter starts off stating that fixing the consciousness on one point is called concentration. We learn this in the practice of asanas and pranayama. If this attention is continuous, it becomes meditation. In asana and pranayama practice, as one makes progress, the attitude of the mind is one of a meditative state. In the advanced stages, if there is a slight drop in this uninterrupted state of awareness, problems could occur. Dharana, dhyana and samadhi together constitute what is called integration or samyama. In this mastery, says Patanjali, comes the awareness of insight. These three aspects of yoga are internal practices. Patanjali says that transformation of consciousness occurs by awareness of the self, which is so subtle that it is aware of the functioning of the layers of the psyche from moment to moment. By sustained refinement of this self-study, the light of samadhi dawns. The yogi gradually attains supernatural powers. He can understand any language, has knowledge of previous lives, and understands the minds of others. By control over the subtle body, the yogi can, at will, suspend the light rays emanating from his body and make become invisible. Sound, smell, taste, touch and form can be arrested. The yogi develops the strength of an elephant. Concealed things, far and near, are revealed to that person. Thorough knowledge of the stars and the solar system is available. The person acquires perfect knowledge of the human body. He can master and overcome any physiological malfunction in the body. Visions of enlightened beings occur. That realized person can leave the body and enter another’s at will. In a nutshell, the yogi can understand everything in a moment, without time as a factor. However, these powers should not interest the yogi for their own sake but only as means towards realizing the infinite. They cannot, anyway, be performed with any negative or base intent; as such superhuman abilities can be achieved only by a mind which has been purified to this fine level. The yogi has now reached the ultimate state of pure existence, when the purity of the soul and his intelligence are the same. All afflictions are washed away. He is a perfected being in the state of Kaivalya. With this, we go over to the last chapter. Kaivalya Pada In this final section, Patanjali draws the attention of the yogi to the soul. He begins with a discussion

of the rebirth of adepts who have descended from the grace of yoga. These people are born according to their previous sadhana. Accomplishment may be due to birth, herbs, incantations, self-discipline or samadhi. Patanjali explains three kinds of actions in our life. He cautions that pure and untainted actions should be upheld and sadhana be maintained. Then the yogi merges with the supreme. Consciousness is one, but thought waves may be in all directions. Out of all these, only those proceeding from a meditative mind are free from reactions and karma. According to Patanjali, the yogi’s actions are neither white nor black, but the average action is always a mixture — white, black or grey. These three types of action leave impressions, sometimes from life to life. Patanjali says that these impressions have existed eternally, just as the desire to live is eternal. The three states of time — past, present and future — are all interwoven, and mingle with the three qualities of nature (sattva, rajas and tamas). According to these qualities, our actions are formed and tie us to the present, past or future. Patanjali speaks of consciousness as not the seer but an instrument of the seer. If consciousness is conditioned, then the object it perceives is also tainted. In other words, perception must be choiceless. If the yogi maintains this supreme attentiveness, he attains what Patanjali calls dharmameghah samadhi. This word means showering of dharma, delightful cloud of virtue. The three qualities of nature now rest and time ceases for the yogi. This does not mean chronological time, but psychological time in terms of tomorrow. The yogi lives in the present; his mind is not on the morrow. The stage of liberation comes when the yogi has fulfilled the four aims of life and transcended the three gunas. The four aims of life are dharma (science of duty), artha (meaning of life), kama (enjoyment of life) and moksa (freedom from worldly pleasures). This ends the exposition of the fourth chapter, Kaivalya Pada. In a little under two hundred lucid and compact verses, Patanjali has given us precise guidelines to living. As I repeatedly stress in this book, yoga is not just a set of esoteric exercises to keep physically fit. It is a complete system of life, with our bodily afflictions and mental fluctuations under control by the practice of concrete rules of conduct. These are universal rules, applicable to every human being, irrespective of creed and color. For whether you are American or Chinese or African or Indian, whether you are a Muslim, Buddhist, Christian, Hindu or Jew, you have the same physical and mental organs as everyone else. It may be argued that all human beings cannot fully follow Patanjali’s advice and evolve into perfect yogis. This is, naturally, an impossible expectation. But his guidelines can be structured to suit our lifestyles; in our daily lives, we can practise yama, niyama, asana and pranayama, keeping ourselves healthy in body and mind. We would then be able to give the best of ourselves, with concentration and commitment, to whatever field we are involved in — as a sportsperson, a medical professional, a business executive, a teacher, a wife and mother, an artist. The world would surely be the better for it.

SECTION I LIFESTYLES We have to apply the discipline of yoga in our daily lives and, consciously or unconsciously, we all do so in varying degrees. Yoga is a way of life and is meant for everyone: not as a fashion, as it has become nowadays, but as fulfilling a real need in life. The need for yoga in daily living was realized ages ago. Explained in this section is the application of the philosophical and practical aspects of yoga for different lifestyles — for the young, the old, for women, for the artist, the musician, the doctor, the sportsperson — and for special conditions like pregnancy.

Health and Food Health Total health is harmony between body, mind and soul. It is perfect maintenance of the internal environment. Today, most of us cannot lay claim to this. Diseases are escalating, though modern medicine is more effective in tackling them. In third world countries, there is a rise in infective disorders like malaria, typhoid and cholera and tuberculosis. Man has traveled the solar system, but is unable to prevent diseases like the common cold. Therefore the significance of preventive medicine needs to be better appreciated. Health is not a static state — it is dynamic, ever-changing. We can never claim that we are always healthy, but only that we are healthy at a particular moment. Health is like a live wire. The moment we feel it, the sensation is energizing. Absence of it is a state when the body and mind are dull and slow. The body can malfunction any time. Disease exists when health does not. The word disease can be split as dis-ease — lack of ease in body and mind. Every disease begins in a rudimentary manner. By the time we subjectively experience the feeling of illness, it has progressed further. The more sensitive we are, the easier it is to feel bodily dysfunctions at the earliest stage. We must try to understand everything about health and disease, and how the two states exist side by side. It is important to remember this: a limitation today could mean a disease tomorrow. Often, warning signals are ignored. A bout of pain in the knees, for instance: the problem disappears after the first episode; after an interval, it recurs in the same mild manner. This may go on for a few months, and suddenly the knee turns arthritic with pain and swelling. While it is obvious that one does not have to be a hypochondriac and rush to the doctor in panic with every little symptom, it is essential to be aware that even the slightest sign of illness needs corrective action. We should immediately search for methods to prevent recurrences. We should make all efforts to prevent ill health, however minor. The body should not be taken for granted. Awareness about health is greater now than ever before, and the means to protect it is available. Exercise has proven to be a tool for preventive health care. Studies have shown that exercise can prevent many ailments. More people are exercising now to keep themselves fit, but they are still a minority. The media has plenty of health journals and magazines to educate the lay person. Yet, in my experience as a medical professional, I find that until one falls ill, no steps are taken to combat

disease. It is very rarely that the relatives of my patients ask my guidance on steps to prevent the very same ailment amongst the rest of the family. Though they accompany the patient who has come to seek relief through yoga, they are surprisingly uninterested in learning yogic methods themselves as prevention. Patanjali explains that ignorance about the body and mind is the cause of all suffering. Health is not just physical. It is moral, mental, emotional, physiological, psychological, and spiritual. Unless spiritual health is achieved, at least to a certain extent, one cannot lay claim to the realm of health. In this state, all bodily functions, mental functions and every possible activity are totally healthy. In a state of spiritual health, matter becomes metamorphosed to the extent that malfunction is almost impossible. Even if it occurs, the impact is very mild. One who has control over matter has the key to health. This ancient tenet is now being proved by modern science. A simple example is that of pain perception. Persons who have walked barefoot across hot coals, remained bare-bodied in extreme cold, are typical instances of bodily mastery. Such people have enormous will power to cut off external stimuli from disturbing them. Modern science has proved that it is possible for the brain to eliminate pain voluntarily. The mind can withdraw; or rather detach itself, from bodily stimuli. While all of us need not walk across coals to prove this, we need to realize that some degree of mind control is essential for health in its entirety. This capacity will actually help us to change disease states. It has been shown that the ‘will to live’ can draw back a person from the brink of a terminal condition. In a state of samadhi, the practitioner can regulate bodily and mental functions to a very high standard of strength. In today’s world, it is very important to have this strength to counter the many influences that can, with or without our knowledge, damage the delicate and sensitive fabric of our body and mind. Good health results from right diet, adequate exercise and a mind that is stress free. The only possible way to achieve complete health is to follow the guidelines that the ancient texts provide for us, particularly the yoga sutras of Patanjali.

Why has health deteriorated? Health in relation to other concepts of living is often neglected today. It is very easy to discuss the rise of diseases medically, but to look at the problem in a holistic manner is important. Statistical studies have shown that the more affluent the lifestyle, the greater the incidence of certain diseases. Our lifestyles have become very sedentary. Our forefathers led lives with higher levels of physical activity. Every job demanded a lot of physical effort. With better range of bodily movement, flexibility was maintained and they hardly suffered from any of the modern stress-related diseases like high blood pressure and migraine, or mechanical problems like arthritis, spondylitis and low back disorders to the extent prevalent today. Hence, we must set aside time for exercise in our daily life. I see adult patients, who were healthy a decade ago, unable to sit on the ground and get up easily. Due to unhealthy lifestyles, even children suffer from poor posture, backaches, body pains, and stomach ailments. Health is not a commodity to be purchased in the market. It has to be earned the hard way, by trying to get every cell in our body under our control. Many of us give up the struggle half way through and

take recourse to drugs. There is no magical elixir to maintain health, nor is it needed. What is important is to tone up the blood flow, maintain flexibility, and massage the internal organs. Movement and change of posture alters the spatial relationship of the organs inside the body, leading to a healthy neuro-circulatory and metabolic state. Poor dietary habits cause ill health. The quantity and quality of snack food available these days is greater than before, and children secure unhealthy eating habits. The social environment is also not conducive to good health in children. There are too many distractions and the mind is easily swayed. Movies, television and video games which kill the natural creativity of children, as well as the excessive pressures of schooling, can all have an adverse effect on the child’s mental and physical health. The world around us is changing. Environmental and ecological damage is widely prevalent. Atmospheric pollution leads to a host of maladies as does contamination of our water resources. Consumerism is on the rise. We are continually being lured by the advertising world to want more and more of everything. Socially, the fabric of today’s world is under strain. Religious fundamentalism is gaining ground. There is widespread decay in moral standards. The cause for so much chaos in our life today — social, political, religious or otherwise — is due to the lack of that morality which exists in the inner recesses of our own consciousness. Disease starts with decay in moral standards. As the yamas and niyamas are totally ignored, insomnia, hypertension, cardiac diseases, diabetes and a host of other stress-related disorders arise. System break down under stress is well known. The immune system is often one of the first to succumb, and this leads to an altered state of intelligence in the biological processes. Frequent infections and even disorders like cancer are the outcome. There is growing evidence to suggest the link between the mind and the immune system. Under stress harmful chemicals which damage the organs in the long run are released in excess. A business person is under stress to perform. Altered lifestyle leading to late nights, excessive socializing, and poor food habits with no time for recuperation affects health. Many proudly claim to be able to jet around the world frequently, asserting that they have no health problems. However, disorders start after years of abuse. At that time, it may be too late for a cure. Consider the athlete who is under stress to win. They consume drugs and then suffers a host of other problems — disqualification, consequent mental stress and damage to the body due to the drugs. All this is because they have to win. In today’s competitive milieu, you feel you have to prove you are the best and then after many years you say, “I can’t take the constant stress.” Do your best so that you feel you have worked honestly, but don’t let the result affect you. If you play, play for the beauty of playing; work for the sake of work; then nothing will worry you and ill health is kept at bay. Does this sound too idealistic? This is the only way to health in its entirety. To the person who is uncompromising about this, disease could be an unknown word. Cancer, high blood pressure, diabetes, coronary problems: these are the major killers today. It is very easy to keep away many of these diseases if you know how. Several disorders like lung ailments, disc prolapse, nervous disorders, altered menstrual cycle,

arthritis, are due to mistreatment and neglect of the body. The person with a back problem is too often a type who has stiff spinal muscles, does not exercise and has bad postural habits. We all know that smoking is unhealthy on account of inhaling toxic materials. Due to various reasons (even though medicine has adequate proof about their harmful effect in causing cancer), cigarettes are still available to man, and he succumbs. High blood pressure, as in essential hypertension, is clearly due to a poor lifestyle. The body is a factory with a precise internal order. Temperature maintenance is consistent, repairs occur, toxins are thrown out, and defense mechanisms work all the time. The functions are manifold. If there is constant stress on the body in any form, the blood vessels start shrinking in response to the neural command. As a result, the blood pressure rises inside the series of tubes which make up the circulatory system. Instead of tackling the root of the problem, which is to change the lifestyle, doctors prescribe drugs. No doubt the pressure has to be reduced, but the emphasis must be to make the patient live without drugs whenever possible. This is now possible with a wealth of new facts about hypertension. One important point we must remember is that the human body will not respond to constant drugging. The system will become unresponsive in the long run, necessitating an increase in the drug dosage and, even then, it sometimes fails. The cells in our body have their memory and intelligence, and react appropriately. It is this intelligence that is damaged due to abuse and neglect. We can fall ill sometimes inspite of following a healthy lifestyle. This also has its logic. Medicine has no explanation for this, but yoga says that if there is weakness at any level in the body and its koshas (sheaths), illness results. (I have discussed koshas in the chapter on the nervous system. These are subtle layers of the body where the energy centers reside).

Heredity and environment Studying the yoga sutras, we realize that the yogi is in command of the body and its elements. He is also in tune with his surroundings. All of us may not be realized yogis, but we can certainly take steps to have a healthy genetic framework and environment. Heredity is what we create for ourselves. Unhealthy lifestyles alter the DNA structure-the basic material for genetic information. It consists of amino acids, which are fundamentally protein in nature. If the sequence in which the amino acids are paired is altered, the message transmitted to the build-up of tissue material and subsequent function is different. Aging processes can alter DNA causing congenital anomalies if a woman conceives later than medically permissible. The child inherits factors according to the parent’s lifestyle. Inheritance is not outside our control. If a sick man regains his health, his genetic material also turns healthy. This, to a great extent, is affected by the environment in which we live. Alcohol consumption is on the rise. This damages the cells of the body sparing no organ. Alcohol affects all facets of our life — social, ethical, moral and spiritual. It is one of the oldest evils of our society and has still not been eradicated. When we know that a particular substance has a toxic effect on the body, why touch it at all? Habits die hard and it is better not to encourage such addictions from the beginning.

On a long distance flight, a pregnant lady was seated next to me. After take off, some persons started smoking. I noticed that this was in the non-smoking section of the cabin. The lady requested them to stop smoking but got a rude reply. The purser could not stop them either. These people did not have the will power to refrain from smoking even for a little while, nor did they have the basic courtesy to oblige a fellow passenger, especially when she was pregnant. We all know about the hole in the ozone layer. We also know the harmful chemicals that increase the size of the hole. Yet, we procrastinate, and action often comes late, if at all, due to vested interests. When the air we breathe is so polluted, how can we be healthy? Noise and chemical pollution affect all the cells in our body. If the world changes over to batteryoperated cars, incidence of lung ailments will reduce. Loud music and excessive use of headphones, can damage our hearing. Yet we ignore this. Patanjali says, Heyam dukham anagatam. (heyam = to be prevented; dukham = sorrow; anagatam = future or hidden.) (Iyengar, op.cit., “Sadhana Pada”, II.16): “The pains that are yet to come can and are to be, avoided.” We do not know what unknown diseases are in store for us in the future, so let us start protecting ourselves from this moment. The refinement in health should be such that we are sensitive to the slightest change in our cells. This is possible by constant training from childhood. I would like to discuss the aspect of sleep. This is perhaps the most abused function today. It is not the quantity or the quality of the sleep alone that matters, but also the time at which we sleep. Biologically, the body is geared in such a way that the levels of cortisol — a very important energygiving chemical — is at a peak at 8 in the morning and lowest in the evening, (when our energy levels are at low ebb). It is healthy to retire at around 9:30 p.m. and rise at around 5 a.m. We would get seven hours of sleep though, for a healthy person, five hours are sufficient. Many of us retire at midnight or even later, and this carries on for many years. This is very harmful to the brain and other organs, and creates stress-related disorders in the long run. I have seen patients with hypertension who were very health conscious and were teetotalers. They had no other health problem, and family history was negative for ailments. Even with adequate medication and aerobic exercise, the pressure did not come under control. On further questioning, it was found that they slept at 2 to 3 a.m. daily. On altering this, the blood pressure dropped within a few months. This is to illustrate the importance of sleep. During sleep, the organism recuperates, and this is very biologically important. Many of us suffer from insomnia because of environmental disturbances. If we ensure that the immediate surroundings are quiet and orderly to the extent that is practically possible, then the mind is not influenced constantly by noise. Noise is not just physical. Mental agitations also constitute noise. I do not know if you have experienced this, but if you stay in a place that is very quiet, you sleep very well. Many of us live in big cities with plenty of mental, visual and auditory stimuli. This constant bombardment prevents us from refreshing our minds. Patanjali advises meditation to stop restlessness. In this state, the mind goes to the root of each problem and finishes with it, and then sleep gives complete rest to the organism. We experience a quality of sleep so deep that we wake up feeling refreshed. This means that the mind withdrew

completely that total rest was obtained. The science of meditation is useful in reducing stress on the body and mind. It is well known that stress activates and accelerates the build-up of arterial blockage. Stress is a challenge to the living organism. If the response is inadequate, there is multi-organ strain. The machine breaks down and one such effect is nervous exhaustion. This can lead to a variety of disorders like asthma, coronary problems and low blood pressure. The human body is a factory of chemicals. All functions are chemically driven. The brain is the powerhouse of energy, and aging of our body may be pre-programmed. It is possible to influence this by a healthy lifestyle. As we become older, our body and mind should remain younger than the actual chronological age. Generally, people 45 years old may look their age; however accelerated wear and tear causes premature aging. The Yoga Vasishta says: “When the mind is affected, the body completely follows the disturbance. Due to the disturbance, the vital energies flow, abandoning evenness. When the vital energies flow unevenly, the channels of such energy are reduced to an adverse state. Some channels go to a state of fullness and some others to the state of depletion.” (Samvid, op.cit., 716-718). Western medicine labels this as the mind affecting the body; our ancient sages realized this long ago. To quote again from the same source: “When desires are springing up excessively, when the stupidity in the mind is not conquered, by taking bad food, by occupying bad places, by working at improper times, by the arising of evil actions, by the bad consequence of association with evil persons, and by the generation of bad emotions, when the vital energy is reduced to an adverse state due to depletion or excessive fullness in the continuous channels of nadis (arteries, veins or nerves), and the body is consequently weakened, physical disease, the cause of indisposition, arises in the body due to such defects.” (ibid., 712-715). We began this chapter with the problems faced by the body and we end with the mind. Patanjali says, the mind is the cause of all problems- root out the latent unhealthy impressions in the mind and we will have a healthy human being. If we have that quality of quietness in our daily life that pranayama and asanas give to our cells and the quietness in our mind and intellect that meditation gives, then we will know what true health means.

Is there a solution? Sure there is, provided we look for it. It requires a certain honesty and practical approach to the problems of living, a good routine of daily exercise, and the right food. Regulation of sleeping hours is essential. We must know the limits of our body and should not push it too far. Any exercise is good for the body. It has been shown time and again that regular exercise gives certain clear cut physiological benefits to the body and mind. Awareness about this has certainly risen over the decades. Another component of good health is proper food. Intelligent eating habits are very important for health. Many people have the mistaken notion that health is a one-time investment. I have, in my clinical

practice, often been asked whether it is possible to exercise for a short period and remain healthy for life! The very question contains the answer. None of us ever question the need to brush our teeth every day of our lives. When it comes to maintaining health, we desire shortcuts. Children should be trained right from a young age to think along correct lines for attainment of health. This does not mean one should be a health fanatic, but that one has to realize that the body needs to be looked after. Moderation in diet and exercise is the key to health and the necessity to inculcate this awareness in children is very important. Let us now study the value of right food and understand what we need.

Food The moment this word flashes across our minds, our thoughts wander back to the delicious fare we had a few days ago. Our mouth waters at the very recollection, and we wish that we could eat that stuff again. Food is what the body needs to survive. It is what the mind needs for right energy. At the same time, we should be careful not to indulge in excess food intake and to eat just the amount we need to lead healthy lives. Food should be tasty and simple. It should not be eaten in a manner that will necessitate medical care later on. Many of the ills of today’s world are due to eating the wrong kind of food at the wrong time, excess food that the body really does not need, too much snacking which only adds weight, and eating in unhygienic conditions. Affluent societies suffer from the ills of excess and rich food. The poorer ones suffer from not having enough of it. The food that we eat is assimilated for growth and maintenance of tissues. Plants can manufacture their food from the soil, but man depends on plants and animals for food. We have a variety of foodstuff to choose from. Worldwide, there is a wide variation in food habits depending on racial characteristics, geographical location, customs and traditions. Animals eat in order to satisfy their hunger and to grow, but man is the only animal who eats for pleasure too. This is responsible for a number of diseases, if carried beyond limits.

What are foodstuffs? Food is classified as cereals, pulses, nuts and oil seeds, fruits and vegetables, milk and its products, and meats. All of them contain certain nutrients which are used by our body. These nutrients are proteins, fats and carbohydrates. The proportions of these vary from source to source. Vitamins and minerals are other nutrients. We need a certain quality and quantity of all these nutrients to live healthily. A well-balanced diet includes them all in the right proportions.

Proteins

Proteins are the building blocks of the cells. Without these, the cells of the body cannot grow and multiply properly. The rebuilding of body tissues is done by proteins. Substances called amino acids are the basic constituents of proteins. Enzymes are factors that help in various important metabolic reactions in the body. These, and certain immune factors (antibodies), are also made up of protein. Most foodstuffs like meat, fish and eggs are rich in protein. In the vegetable kingdom, pulses are very rich in protein, often exceeding those found in animal foods. Rice and wheat contain less protein. The outer layers of cereals are richer in protein than the inner starchy area, so rice that is highly milled is poor in protein. The quality of rice protein is better than that of wheat. Leafy vegetables are poor sources of protein. There are around twenty different amino acids found in our food. The body can synthesize most of these in the liver and also obtain them by inter-conversion. However, there are ten essential amino acids that cannot be made up by the body and have to be supplied in the diet which finally determine the quality of the protein. Eggs and milk which have the best quality protein are frequently used as a base for comparison. In the plant kingdom, there are deficiencies in some of the essential amino acids, depending upon the source, but these can be made up by blending a variety of sources. Cereals, in comparison with egg protein, are poor in the amino acid lysine, while pulses are poor in methionine. Thus, by blending cereals and pulses we can obtain good protein. I have given a table below to give you an idea of the value of proteins in several common foodstuffs: Nutritional values of proteins in some foodstuffs

(Source: Gopalan et al, Nutritive Values of Indian Foodstuffs, National Institute of Nutrition, Hyderabad, India, 1984.)

Digestive pathway of proteins Digestion of proteins begins in the stomach, with hydrochloric acid secreted by the cells lining the stomach. Digestion continues in the small intestine. The enzymes here break the proteins into amino acids and polypeptides, which are larger units. Absorption occurs through the small intestine within two to three hours. From here the amino acids get into the portal circulatory system, and enter the liver and the skeletal muscle which are the major stores. However, before they can be used, nitrogen must be removed. This is done with the help of certain enzymes and most of the nitrogen is excreted in the form of ammonia and urea. Apart from the kidney the liver is a major organ involved in this degradation. During starvation, proteins are broken down to amino acids to be used for important functions of the brain and the kidneys. Amino acids are converted into glucose for the energy necessary during starvation and exercise. When the input of nitrogen equals its output, we are said to be in a state of nitrogen balance.

How much protein do we need? The minimum protein requirement for an adult is one gram per kg of body weight. It can be seen that animal sources of protein are much richer than plant sources, but if we blend many sources in the plant kingdom, we can get what we need. Children need a large amount of protein as their bodies are growing fast. This is best met by milk, of which three or four glasses a day is essential. Buttermilk is also a good source. There is a misconception that only ingestion of lean meat provides good protein. In fact, many world class athletes are pure vegetarians. There is no need to consume flesh foods as they are toxic to the system in other ways. This I shall discuss later. The amino acid alanine plays an important role in maintaining glucose levels during exercise. Fats Fats (lipids) are graded by their solubility in organic solvents, but not in water. The most common lipids are lecithin, cholesterol and triglycerides. Cholesterol is necessary for the formation of steroid hormones and bile salts used in fat digestion. Triglycerides are a concentrated source of energy. They supply more energy per unit weight than proteins and carbohydrates. Fats provide essential fatty acids like linoleic, linolenic and arachidonic acids. These play an important role in several metabolic processes, and their deficiency causes a clinical condition called ‘toad skin’ (phrenoderma). In our normal diet, the fat content is derived from oil used in cooking. The oil should contain polyunsaturated fatty acids. These do not contribute to a rise in the cholesterol content in our body. Cereals, pulses and vegetables contain little fat, while nuts are rich in fat though the quality of monounsaturated fatty acids makes them beneficial for health in limited quantities. Fat metabolism and usage Most of the dietary fat is in the form of triglycerides. This is glycerol with both saturated and unsaturated fatty acids. Fatty acids provide an important energy source. The entry of fat into the duodenum causes many enzymes to be released along with bile salts synthesized from cholesterol in the liver. Cholesterol has the chemical structure of a steroid molecule. In the cells of the intestine, the dietary triglycerides and cholesterol combine to form chylomicrons. Pancreatic lipase, colipase and bile salts break down this combination into fatty acids and monoglycerides. The fatty acids enter adipose tissue and muscle through the lymphatic circulation. The remaining chylomicrons and cholesterol then enter the portal venous system and into the liver. Thus, dietary triglyceride reaches the liver. Some of the cholesterol is converted here into bile acids to later reach the intestine to act as a detergent to facilitate absorption of dietary fat. The liver also forms triglycerides from ingested carbohydrate. The triglycerides are converted into lipo-proteins. These are mixtures of cholesterol, protein and other compounds. These lipo-proteins are classified as high (HDL), low (LDL) or very low density (VLDL) types. The liver first forms VLDL, which becomes LDL with the help of enzymes. LDL is very rich in cholesterol — about 75% of ingested cholesterol is in the form of LDL which supplies cholesterol to renal, lymphocytes and adrenal cells

where the steroid hormones are formed. Thus, LDL supplies cholesterol to extra-hepatic sites and this cholesterol is returned by such cells as HDL. There are, therefore, two sources of cholesterol: that which is ingested and that which is synthesized in the liver. In ischemic heart disease (IHD), where the coronary vessels are blocked, it is the levels of these lipo-proteins that are clinically important. Generally, a lower than acceptable HDL level and a higher than permitted LDL level can be a predisposition to IHD. Total cholesterol should not exceed 240 mg per dl and triglycerides should not exceed 250 mg per dl. Desirable levels of HDL range between 27 to 98 mg per dl and LDL 80 to 130 mg per dl. In an ultimate analysis, if we adhere to a low fat diet, we are healthier. We need 40-60 grams of fat per day, and 15 grams of vegetable oil will give us the essential fatty acids needed. Margarine may not be always suitable. Moderation is the key here. There are a variety of drugs that help reduce lipid levels. Bile acids can be removed by resins, and since more cholesterol is used to form bile acids, the level of cholesterol LDL reduces. Statins reduce cholesterol synthesis by inhibiting HMG-CoA reductase — the rate limiting enzyme in cholesterol synthesis. Tolerance to this varies due to inherent side effects (commonly muscle pain and fatigue among a host of others). Yet another drug, gemfibrosil, reduces VLDL and raises HDL. The resins produce nausea, bloating, abdominal pain, and the others produce rash and liver toxicity in addition. Cholesterol absorption inhibitors are another class of drugs used. It is beyond the scope of this book to deal with the drugs involved in regulating cholesterol levels. Though we may consume a low fat diet, the individual metabolism can convert anything preferentially into fat, causing undesirable weight gain and other diseases. It is no use stating that we eat low fat foodstuff; we should also be aware and alert about the idiosyncrasies of our own bodies. Usage of fat during exercise Fat is an important source of energy, especially during prolonged exercise. Generally, usage begins at one site and is completed at another. The first step is the breakdown of triglycerides from fatty tissue. Then fatty acids, which are the broken down products, are transported to the muscles, where uptake and activation to higher levels of energy occur. They then enter into the mitochondria, which are the power houses of the cells, where they are oxidized and, in the process, energy is released. Various tissues like the heart and liver are highly adapted for lipid usage. Others like the brain and red blood cells use glucose as the main source of energy. Training and lifestyle influence the utilization of fat as more mitochondrial mass is available in trained persons. Sedentary life styles predispose to fat accumulation. Again, usage is highly individualized and the amount of physical activity needed for each person has to be calculated. The greater the physical activity, more the fat that is used up.

Obesity and health Obesity refers to an excess of body fat. It means more fat is being stored than used up. This state is

associated with greater morbidity and mortality. All our body functions are affected. The heart finds it more difficult to pump blood through the increased amount of body tissue. The joints are under greater mechanical stress. The mind is dull and a general vegetative state pervades. Huge amounts of money are being spent researching better diets. All that needs to be said is that, if we eat sensibly, obesity does not pose a problem. It may be an inherited pattern but, if an individual is careful with diet and has healthy exercise habits and, most important of all continues this lifestyle, then obesity can be avoided. Childhood obesity is very common due to many reasons. Parents are responsible for this decay in their health and should be strict right at the start and teach them sensible dietary habits which could be inclusive of reasonable indulgence! Our body mass index (BMI) is a very useful indicator of health status. BMI is a fairly reliable indicator of total body fat, which is related to the risk of disease and death. The score is valid for both men and women but it does have some limits. It may overestimate body fat in athletes and others who have a muscular build. It may underestimate body fat in older persons and others who have lost muscle mass due to specific reasons. Experience has shown that habitual yoga practitioners have a reasonably good BMI. However, genetics influence this factor too.

How does obesity affect us? Heart and blood vessels The pump function of the heart is compromised and premature heart failure could result. Hypertension due to constricted blood vessels does not respond well to medication because the excess weight prevents the blood vessels from reacting to the action of the drug. The circulatory system is thus very unhealthy. Poor circulation, in turn, leads to a host of other disorders like strokes, tissue starvation, poor cellular function and absorption, and consequent ill health. Associated dyslipidemia (altered blood lipids) can cause IHD. The lungs Reduced vital capacity and labored breathing occurs and the heart consequently struggles. Facial flushing and easy exhaustion is common. There is a load on the intercostal muscles and lungs. The diaphragm struggles in its movement up and down. It is difficult to withstand altitudes and resistance to infections is poor. Muscles and joints The muscles are infiltrated by fat cells, their contracting capacity and power reduced. The joints are damaged due to excess weight, especially weight-bearing ones like the hip, knee and ankle. Premature osteoarthritis can occur. By now, the obese person is a patient. As movements are affected, there is poor muscle blood flow. This creates an unhealthy skin, as it is through the muscles that the blood and other nutrients reach the surface. The joints are under stress; their mechanical movements are poor. Setting right degenerative joint conditions posts a problem, as the weight makes the practice of asanas difficult. Weight can be reduced by endurance training in phases, but the presence of a medical

condition might preclude training. Inactivity worsens muscle wastage. The abdominal muscles can protrude and drag the spine forward. Predisposition to a hernia is very likely. Surgical correction of a hernia in the obese yields poor results as the excess fat makes for poor muscle tone, even if an abdominoplasty (plastic surgical correction) is performed. The spine becomes unwieldy. Paradoxically, fat persons are more flexible than lean persons as the fat makes the muscles soft. Yet the very bulk makes for clumsy movements. The spinal joints suffer premature degenerative changes. Slipped discs can be very difficult to treat, as both surgery and yogic practice might fail to produce results due to the excess weight. As there is little space for manipulation of joints, even assisted movements are difficult with props. The ankle joints often swell due to excess pressure. The lower limbs also swell due to poor venous and lymphatic return. In short, the movements of the body, which should function like a well-oiled engine, totally break down. Digestive and excretory systems The liver is infiltrated with fat cells (fatty liver). Gall bladder contractions are poor due to unhealthy muscle tone. Owing to poor blood flow to the organs, gastric acid secretion is impaired. The contracting capacity of the intestine (peristalsis) is inadequate; creating problems of constipation and retention of stools (the transit time is prolonged). Toxic products, retained in the colon, can cause colon cancer. The kidneys find it very difficult to function healthily, and the excess fat in the system can create premature renal failure. Nervous and glandular systems Excess fat prevents healthy transmission of electrical impulses to and from the brain. The extra fat can get lodged between the nerves and create local pain. This will need surgical removal. Excess fat in the system is harmful to the mind and the brain. In a study, a group of athletes was fed a high carbohydrate diet, while another group was fed a very high fat diet. The latter group did not fare well in the clinical assessment of their mental faculties. However, this concept (avoidance of a high fat diet) has existed long before medical guidelines were available as, according to yogic science, the intellect and the mind become dull if the body has excess fat. Poor blood circulation affects healthy output of the endocrine glands. Hypothyroidism is common. This creates a hypo-metabolic state, affecting all functions of the body. Replacement of thyroid hormone is advisable. Energy levels are also low as the adrenal glands are not stimulated. Unless we exercise, the adrenal glands, which provide adrenaline and other energy-giving steroid hormones, do not get toned up and they function poorly. Glucose intolerance can occur as the pancreas struggles against excess body fat. The skin The excess fat creates a lot of skin folds on the surface of the body. In the groin region, for example, recurrent fungal infections are common due to sweating. Obese women suffer irritation occurring under the folds of the breasts. Dermatitis occurs due to friction between layers of skin. Sweating

patterns are altered as the skin folds prevent proper aeration of the area where sweating occurs. Sweat retention produces infection in that area. Due to the bulk of the skin, proper circulation of blood and fluids is hampered. The skin often becomes dry and irritated. Nursing obese patients is problematic. It becomes difficult to even move them around. The overweight person will do well to bear this in mind. The best method to prevent all these problems is to be sensible in our eating habits. Eat only when hunger occurs. This would mean two principal meals a day with breakfast, and a little snacking in between. Regular exercise burns up excess fat and, even if we have eaten a little excess the previous day, it is taken care of.

Carbohydrates Carbohydrates are a class of foods which include glucose, cane sugar, milk sugar and starch. They form the main source of energy for the body. Besides these, many foods contain substances called cellulose and hemi-cellulose. These are the indigestible components of plant cell walls, called fiber. We shall discuss this in detail a little later. The main product of dietary sugar and starch digestion is glucose which is released into the blood. The dietary sources of glucose are numerous. Most dietary sugars, after their absorption in the intestine, reach the blood in the form of glucose. The cells of the body absorb glucose in the presence of insulin. The nervous system uses glucose in large measure. The metabolic process by which glucose is broken down is called glycolysis, by which sugar is made available to the cells for energy. This is the main source of energy for muscles. There are two types of glycolysis — with or without the presence of oxygen. Lactic acid is one of the breakdown products of glycolysis. In the process of glycolysis, energy molecules, chemically called adenosine-triphosphate (ATP), are formed. ATP is the energy molecule of cells. If it is used up, the cells have no energy. Glycolysis is regulated by enzymes. The formation of glucose from glycogen (glycogenolysis) is also possible. Skeletal muscle stores glucose in the form of glycogen, the breakdown of which gives the cells energy. This also occurs in the liver and kidney. Neo-glucogenesis is conversion of pyruvate and lactate which are other sources of energy, to glucose. Glucose regularization during exercise The liver is responsible for maintaining normal blood levels of glucose during exercise. Instead of blood glucose, muscle glycogen is used as fuel. The non-exercising areas of the body continue optimum function due to a normal level of blood glucose. During short duration, high intensity activities like sprinting, the liver is not a major player. Muscle glycogen is adequate for this. Insulin regulates blood sugar levels and we should understand its response to exercise. Blood levels of glucose decrease with exercise and insulin level follows suit. This prevents hypoglycemia, and enhances lipolysis, making free fatty acids available for exercise. In the trained individual, the reduction is not as much as in the untrained. When blood levels of glucose reduce, glucagon raises the same by neoglucogenesis and glycogenolysis. Adrenaline and noradrenaline, stimulate glycogenolysis — the former evoking more response than the latter. A healthy man requires 3000-4000 calories per day, while a healthy woman needs 3000 calories.

However this is not a rigid rule and depends on the life style. Seventy percent of these calories should be in the form of carbohydrates. We have now understood how the ingested food is used by the cells of the body for energy and the different mechanisms by which energy is available for the cells. Lactic acid, carbon dioxide and water are the final end products. Depending on the type of physical activity and diet, energy reserves are formed. If we exercise consistently every day, all these mechanisms of conversion and interconversion are well stimulated and healthy. This also depends upon the kind of exercise. During yoga practice for example, energy is fed to the cells rather than used up, and that is why we emerge feeling fresher than when we began the session. In other exercises, the cellular reserves are used up and exhaustion occurs. In yoga, the movements are designed to either use or increase the reserves, and this also can be a selective process. The reserves can be built up in any part of the body depending on the asana practiced. The great advantage of yoga is that energy can be built up from a state of exhaustion (there is a limit for this). When the body is fatigued, asanas provide rest and recuperation occurs. It should be stressed that fatigue will increase with other kinds of exercises, if done in a state of exhaustion. Lactic acid formation as a result of yoga practice is less than other exercises.

Fiber Our discussion on diet is incomplete without talking about fiber, the need for it and its important properties. Fiber, also called roughage, is the indigestible component of a plant cell wall. Obviously then, animal foods lack fiber. The laxative effect of roughage has been appreciated for a long time — since Hippocrates. Physicians use fiber as a very good tool in many clinical problems. Before we go on to this, we shall look at the physical properties of fiber — its water-holding capacity, cat-ion exchange capacity and bile acid adsorption. The major influence of fiber is in the upper gastrointestinal tract owing to its water-holding capacity. The water-holding capacity of fiber depends on whether it is of plant or vegetable origin. Cooking has been shown to affect this capacity. The different properties of fiber depend on the source of the material and the method of ingestion. In the colon, there is a complicated interplay of fiber, colonic bacteria and bile salts. What is the role of fiber in medicine? Constipation Fiber plays a very important role in the treatment of constipation which is defined as the infrequent and difficult passage of small hard stools, accompanied by a feeling of incomplete evacuation in the rectum. The water-holding capacity of fiber is of value here. Fiber is that which is undigested and forms the bulk material; the stools are softer because of the higher water content. Fiber aids complete evacuation. The amount of fiber that has to be given to each patient is highly variable. Ano-rectal disorders Ano-rectal disorders include piles and fissures. The passage of soft stools allows the fissure in the

anal canal to heal; otherwise, the friction of the fecal matter would rupture the area, creating bleeding. Patients with complaints of piles (varicose veins of the rectum and anal canal) have a more comfortable motion with higher quantities of fiber. The dose, of course, has to be regulated. Colonic disorders A common disorder due to poor fiber content is diverticulosis. This is a condition where the intestinal wall forms sac-like projections along its entire length. A diet low in fiber raises the pressure of the colonic contents and, over many years, the pressure exerted by the fecal material distends the wall of the intestine. If left untreated, this creates chronic inflammation in the colon. It can sometimes become a surgical emergency, when the sac-like portion is excised. Diabetes mellitus Fiber, being a highly viscous material (especially if the Indian cluster bean is used as the source) delays the absorption of sugar from the intestine. This prevents and controls the rise in fasting and post-prandial levels of sugar. Fiber and colonic bacteria The normal colon is populated by a wide variety of bacteria. In the stomach and small intestine, there are no bacteria, except in pathological states. The acid in the stomach prevents the growth of bacteria. Acid secretion is not as efficient with aging, when the stomach could be invaded by bacteria. Elderly individuals have impaired digestion. Fiber traps many food substrates on its surface, thus providing the bacteria nutrition and an area for fermentation. The type of fiber determines the quality of fermentation and the nature of bacteria acting on it. Excess fiber intake can cause flatulence. Sometimes, there can be a foul odor (due to fermentation), even with good food content and without excess of any foodstuff. In such cases, a short course of antibiotics eradicates some bacteria, while others dominate the fermentation scene, and the situation is rectified. How much fiber do we need? Studies have shown that around 40 grams of fiber per day is the minimum consumed by vegetarians around the world, without an obvious effort to include it in their diet. This amount is the right dietary requirement and a sensible vegetarian regimen, combining varieties of foodstuffs, provides it. A predominantly non-vegetarian diet will, therefore, create problems in the long run. Problems of constipation, colon cancer, diabetes, poor digestion and absorption are all because of poor fiber intake. We must also remember that excess fiber intake can produce diarrhea or constipation. There is adequate evidence to show that a vegetarian diet is the healthiest. Vitamins Vitamins are organic substances which are very essential for the metabolic functions of the body.

Vitamins A, D, E and K are fat soluble, and the B and C groups are water soluble. Vitamin A Vitamin A is necessary to maintain the integrity of the epithelial tissues of the body. Its absence creates wasting of the sclera of the eye and cracking of the corneal surface, resulting in ulcers. Gradual loss of night vision and ultimately complete blindness occurs. In the retina, this vitamin is the base for a series of molecular reactions responsible for vision. Lack of vitamin A also causes dry skin (toad skin). An excess of vitamin A, however, causes nausea, vomiting, giddiness, headaches, and irritability. Vitamin A is present in animal foods like butter, ghee, whole milk and egg yolk. The liver oils of some fish like cod, halibut and shark are some of the richest sources of this vitamin. In vegetables, Vitamin A is present as a precursor form (carotene). Spinach, curry leaves, coriander leaves, mint, drumstick leaves, mangoes, papaya and tomatoes are some of the rich sources of this vitamin. The dark green leaves of the cabbage are richer than the inner white leaves. The vitamin A potency of milk depends on the carotene content of the grass that the cow consumes. In Europe, for example, milk is poorer in carotene content in winter than in summer. Ghee (clarified butter) from cow’s milk is richer in vitamin A than that made from buffalo’s milk, as the latter contains only pre-formed vitamin A. The B group of vitamins Thiamine (vitamin B1) referred to as the anti-beriberi factor, acts as a co-enzyme in many metabolic reactions. Deficiency leads to inhibition of these reactions and the accumulation of the metabolites. Thiamine prevents the disease beriberi, which has two forms — the dry and wet. In the former, there are neurological symptoms of numbness and tingling in the hands, and nerve palsy. In the wet form, the symptoms are predominantly cardiovascular. The heart faces a circulatory overload and cardiac failure occurs. Chronic alcoholics often suffer from thiamine deficiency due to nutritional inadequacies. Thiamine deals with the metabolism of carbohydrates, and the need is greater in the wake of increased carbohydrate intake. Diets based on whole wheat, millets, raw and hand-pounded rice supply this vitamin in adequate amounts. Yeast, rice, un-milled cereals, pulses and nuts, particularly peanuts, are rich sources of thiamine. Besides thiamine, the other vitamins in the B group are known as the B2 complex. They include riboflavin, niacin, pantothenic acid, vitamin B6, folic acid, and vitamin B12. Riboflavin deals with several oxidation processes in the cells. Symptoms of deficiency are manifested as soreness of the tongue, cracking of the angles of the mouth, burning of the eyes, and scaling of the skin in the region of the nose and the angles of the lips. Milk and milk products including skimmed milk, buttermilk, whey, cheese and yoghurt, green

vegetables, wheat, millets and pulses are the various sources of riboflavin. Rice is a particularly poor source. Niacin is formed mainly from the amino acid, tryptophan. It is an essential co-enzyme in many oxidation reduction reactions. Deficiency of this vitamin produces a condition called pellagra which is an inflammation of the skin (dermatitis). It appears on the parts of the body exposed to the sun such as the face, legs, and the back of the hands. Whole cereals, pulses and nuts, particularly peanuts, are rich sources of this vitamin. Milk, being rich in the amino acid tryptophan, prevents the occurrence of pellagra. Vitamin B6 (pyridoxine) acts as a co-factor in amino-acid metabolism. It is principally involved in the conversion of the amino acid tryptophan to nicotinic acid. It is also important for the synthesis of the haem precursor in red blood cells. Deficiency in this causes some types of anemia and inflammation of the angles of the lips. Vitamin B6 is widely distributed in all foods and this is the reason that clinical deficiency of this vitamin is rare. Vitamin B12 is essential for proper synthesis of DNA. It acts as an essential co-factor in the conversion of the amino acid homocystine to methionine. Interruption of this process damages the insulation of the nerves throughout the body. Deficiency also impairs the proper maturation of red blood cells, resulting in specific types of anemia. Only animal foods appear to contain this vitamin and hence vegetarians would appear to risk deficiency, but in practice this rarely occurs. Milk, meat and liver are good sources. Deficiency is usually due to mal-absorption. Many intestinal disorders create such conditions. For proper absorption of this vitamin, the stomach produces the intrinsic factor (IF). This IF-vitamin B12 complex travels to the ileum where absorption occurs. Anemia and its manifestations of giddiness and lassitude, as well as fluid retention and cardiac failure, can result from a deficiency of vitamin B12. In the gastrointestinal system, soreness of tongue and loss of appetite occurs. In the nervous system, the damage to the insulation of the nerves produces numbness of the extremities, in-coordination, and disturbances of mentation. The most common manifestation of B12 deficiency is pernicious anemia, where the secretion of IF ceases due cell loss in the lining of the stomach wall. Other causes are loss of small bowel length after surgical resection, change in intestinal bacterial content after surgery or administration of a course of antibiotics. Several chemicals like anti-cancer drugs and anti-convulsants (used in the treatment of epilepsy and other neurological conditions) antagonize the action of vitamin B12. Folic acid primarily functions in the transfer of some chemical groups to various organic compounds to create building blocks of biologic macromolecules. The causes for deficiency are the same as for vitamin B12. During pregnancy, the need is higher as the fetus consumes most of the maternal stores. Fruits and vegetables are sources of this vitamin.

Vitamin C Vitamin C is essential for proper synthesis of collagen in the body. Humans cannot synthesize vitamin C and need dietary supplementation. Absence of this leads to a reduction in the formation of collagen and its secretion. The type of collagen formed is also altered and cannot be used by the tissues. The result is scurvy, with increased capillary fragility resulting in bleeding, poor healing of wounds, hemorrhages in the joints, and bleeding in nail beds, gums, muscles, and in the abdominal viscera. In infants, bony growth is affected, causing the characteristic deformity of sunken chest and deformed long bones. An excess of vitamin C causes renal stones and interferes with the absorption of vitamin B12. Vitamin C is found in all fresh fruits and vegetables, particularly in green leafy kinds. It is easily prone to destruction by atmospheric oxidation, and when vegetables are dry, the content of this vitamin is lost. Sprouted pulses contain a good amount of vitamin C. The fruit Amla (Indian gooseberry) is a very rich source. Amla juice is acidic and this protects the vitamin from destruction. It contains nearly 20 times the vitamin content of orange juice. Fresh citrus juice is a good way of including this vitamin in our daily diet. Vitamin D Vitamin D is considered both a vitamin and a hormone. The active metabolites of this are influenced by metabolic activities in the liver and the kidneys, and transported to the tissues to help calcium metabolism. Vitamin D is derived from a precursor of cholesterol. When the skin is exposed to sunlight, ultra-violet rays enter the epidermis and create a variety of photo-chemical reactions. After synthesis, vitamin D is taken into circulation by a carrier protein. Entering the blood, it reaches the liver and is metabolized to an active form by the cells of the liver. The kidneys then convert this into a more active metabolite. If there is a decrease in serum calcium, the parathyroids release parathormone which increases the conversion of the vitamin in the kidneys. Deficiency states include liver diseases, renal disease, usage of steroids and anti-convulsants, and intestinal disorders. Deficiency of vitamin D in children causes rickets. In adults osteomalacia occurs. Deficiency impairs the absorption of calcium from the intestine, which in turn stimulates the release of parathormone from the parathyroid. A genetic defect in the chemical synthesis of the vitamin is another factor. Steroids affect the vitamin D-mediated absorption of calcium from the intestine. Excess of Vitamin D occurs in conditions of tumor manifestation like Lymphoma, and Sarcoidosis (thought to be an altered response of the body to a tuberculous infection). However, deficiency states are more common. Excess ingestion of this vitamin causes symptoms like nausea, vomiting, irritability and headaches. Vitamin E The role of vitamin E is to act as an antioxidant and prevent the formation of cellular toxic products. Deficiency occurs with intestinal mal-absorption; dietary lack is rare. The symptoms of deficiency

include gait disturbances, decreased capacity to appreciate the sense of vibration, and neurological disturbances. Vitamin E is widely distributed in all types of food. Vitamin K Vitamin K is essential for the synthesis of some of the factors in the blood that are responsible for the clotting mechanism. It is formed in the gut by the action of bacteria. Deficiency occurs in conditions of fat mal-absorption. Low levels of the vitamin cause hemorrhage. Liver disease reduces levels of Vitamin K causing easy bleeding in patients who undergo surgery. Parenteral replacement is essential before such procedures. Mineral salts A large number of salts are present in the body. We shall consider a few important ones. Calcium: Bones and teeth are principally made of calcium. Children need more calcium than adults, and menopausal and post-menopausal women need more calcium than women who are in the fertile age group. There is about 1 to 2 kg of calcium in our body, and 98% of this is in the skeleton. Calcium in the extra cellular fluid, which is maintained at a constant level, influences the functions of neuromuscular irritability. Normally, we excrete about 100 to 400 mg of calcium per day. Maintenance of calcium metabolism depends upon vitamin D (which enhances its absorption from the intestine), parathormone from the parathyroids (which releases calcium from the bone if needed), and renal regulation of calcium excretion. A decrease in serum calcium results in tetany — tingling in the hands and feet, muscle spasms, bronchospasms, and interference with cardiac neural conduction. An increase in calcium levels leads to loss of appetite, vomiting, constipation, depression and deposition of calcium in abnormal sites, especially in the joints and blood vessels and the major organs of the body. If vitamin D levels are normal, all the calcium from the intestine is absorbed. Milk is an abundant source, including skimmed milk and buttermilk. Leafy vegetables like fenugreek and drumstick, root vegetables like tapioca, and the millet ragi are all very rich sources of calcium. Rice is very deficient in calcium. Some foods which are rich in calcium are also rich in oxalates which can combine with calcium and render them unavailable to the body. But, these kinds of foods are few. In India, the habit of chewing betel leaves ensures an increased intake of calcium. Phosphorus is also a major component of bone and is involved in many of the metabolic reactions of the body. The skeleton harbors eighty five percent of it. In contrast to calcium, absorption of phosphorus is more efficient. Even at low levels of intake, 90% is absorbed. Serum levels of phosphorus are regulated by the kidneys. An excess of this mineral causes bone pain, loss of appetite, muscle weakness and dizziness. Defective growth in children may sometimes be due to low levels of phosphorus. Cereals, pulses and nuts are rich in phosphorus, but may be combined with a substance called phytin, making it unavailable to the body. But dietary deficiency is rarely encountered.

Iron: The total amount of iron in the body is around 3 to 5 gm. It is more in males than in females. Iron exists in different forms: (i) iron of hemoglobin; (ii) tissue iron — this is in two forms, available iron and non-available iron; (iii) transport iron (plasma iron). Hemoglobin iron constitutes around 60% to 70% of the total body iron. Hemoglobin is a complex protein consisting of two parts — haem and globin. Hem is an iron-containing chemical attached to the globin part which is made of polypeptide chains (amino acids organized in a particular structure). Hemoglobin performs the very important job of transporting inhaled oxygen to the tissues and cells of the body. This function is affected by factors such as temperature, and the acidity and alkalinity of body fluids. The level of hemoglobin in males is around 14 gm/dl and 12 gm/dl in females. Vitamins and mineral salts — daily requirements

*Quantities for folic acid, vitamin D, vitamin K and iodine are in micrograms; all other quantities are in milligrams.

Tissue iron can be of the available (also called storage) kind or the non-available kind. Storage iron again is in two forms — ferritin and haemosiderin. In a normal subject, around one-third of the storage iron is in the liver, one-third in the spleen, and one-third in the bone marrow. Haemosiderin is the more stable form and ferritin is the more easily available form. Non-available iron is the muscle

hemoglobin- myoglobin, and iron in the enzymes of cellular respiration. Plasma iron is bound to a specific protein. This protein transports iron to the tissue stores, from these stores to the marrow, and from one storage site to another. In the marrow, ferric ions are released which pass into the cells and are utilized. The serum level of iron is around 120 micrograms per deciliter. This value shows a diurnal variation, being higher in the morning than in the evening. Iron is absorbed only in the ferrous form. Most of the iron available is in the ferric form; in the acidic environment of the stomach it is converted into the ferrous form before it enters the lining of the cells of the duodenum (and the first part of the small intestine). The rate of absorption is influenced by two factors — iron stores and the rate of synthesis of red blood cells. Under normal conditions the absorption exceeds excretion. A high phosphorus diet — like bread, milk and cereals — impairs iron absorption by forming ferric compounds. The cells of the intestine are tuned to sense the amount of iron in the body and act accordingly. Iron deficiency states include menstruation, pregnancy, poor diet, pathological blood loss (ulcers, cancer), and worm infestation. Pregnancy requires extra supplementation. All menstruating women should ensure a diet richer in iron than normal since they lose blood every month. Leafy green vegetables and millets such as bajra and ragi are good sources of iron. Milk is poor in iron content. Sodium and water balance are inter-related. Sodium balance depends on intake and excretion by the kidneys. About 2% to 5% of the body sodium is located in the extra cellular fluids. Excretion by the kidneys is under hormonal control of aldosterone (from the adrenal gland) which retains sodium. The hypothalamus, which is the thirst-regulating centre of the body, is also involved in regulation of sodium levels. Anti-diuretic hormone (ADH) from the pituitary also controls the levels in conjunction with aldosterone. Thus, it is not just one factor that regulates sodium balance. Deficits of sodium and water occur in a wide variety of conditions. If excess sodium is ingested, water level in the body also rises due to thirst. Summarized below are a few conditions of sodium and water imbalance: 1. Combined sodium and water loss — vomiting, burns, diarrhea, sweating, renal disease, diabetes, lack of aldosterone. 2. Only sodium loss — in addition to the above, hormonal imbalance, drugs, pain and emotional disturbances. 3. Excess of sodium — due to water loss by sweating, respiration, hypothalamic malfunction, excessive intake of salt and drugs. Loss of sodium causes neurological dysfunction. Water enters brain cells and swelling occurs. The patient is lethargic, confused, irritable, and convulsions may occur. The cause has to be identified and the condition treated. Potassium is the principal intracellular ion. If blood becomes acidic, it shifts potassium out of the

cells, and vice versa. Potassium is an important co-factor in a number of metabolic processes. The regulation of potassium is under the control of hormones — insulin, adrenaline, and aldosterone. Low potassium levels are caused by factors like (i) poor intake, vomiting, diarrhea and surgery; (ii) renal causes creating alkalinity of the blood, excessive secretion of aldosterone which, while retaining sodium, pushes out potassium; (iii) insulin, antibiotics, and drugs retaining potassium. Symptoms of potassium deficiency include muscle weakness and total paralysis. Rapid reduction in the levels may cause cardiac arrest. The kidneys cannot function effectively in the absence of potassium. They begin to excrete more water than normal. The causes for elevated potassium levels include (i) poor excretion of potassium — renal failure, low levels of aldosterone; (ii) shift of potassium from tissues — burns, injuries, bleeding, reduction in ph of blood, drugs and insulin deficiency; (iii) excessive intake. Elevated potassium levels causes cardiac rhythm disturbances with a gradual slowing down of the heart rate and, finally, total cessation of heart beat. Paralysis of the muscles of the body with respiratory arrest can also occur. Magnesium: An important component of chlorophyll (the pigment found in green vegetable foods), magnesium is present in all the tissues. Deficiency causes growth failure, behavioral disturbances, cardiac rhythm disturbances, weakness, tremor and tetany. Zinc: Nearly 99% of the total body zinc is inside the cells. Pregnant women require more zinc. Zinc levels are low in conditions of liver disease, intestinal disorders, acute heart attacks, malignancies, infections, renal disease, burns, surgery, and high catabolic states. Symptoms of deficiency include growth retardation, hair loss, dermatitis, immunological impairment and impaired spermatogenesis. Toxicity occurs following inhalation of fumes by welders, or through oral or intravenous administration. Inhalation of fumes leads to fever, chills, headaches, cough and excessive salivation called metal fever. Iodine is the basic raw material for thyroid hormone synthesis. It is usually found in the water and food that we consume. Iodine enters the blood in the form of iodide and enters into the thyroid for hormone synthesis. Iodide is removed from the plasma by the kidneys and thyroid. Deficiency of this causes swelling of the thyroid gland, known as goitre. Due to lack of raw material, the thyroid hormone is not synthesized. The pituitary gland continues to stimulate the thyroid in an effort to make the gland produce the hormone (pituitary thyroid feed back mechanism). If the levels of thyroid hormone are normal, the pituitary does not stimulate the gland more than necessary. During pregnancy, the need for iodine is greater due to the demands of the foetus. Maternal hypothyroidism is a common occurrence due to dietary deficiency of iodine especially in third world countries. This has now been solved to some extent by the inclusion of iodized salt in daily cooking. Copper: The liver, kidneys, heart and brain contain high amounts of copper. Copper levels increase in acute heart attacks, tumors, infections and leukemia. Decreased levels occur in malnutrition, renal disease, and several diarrheal and mal-absorptive disease states. Lack of copper causes anemia, growth failure, defective pigmentation of hair and degenerative changes in the lining of the major

blood vessels like the aorta. Toxicity causes hepatitis, tremor, mental deterioration, anemia and renal failure. Cobalt is a component of vitamin B1. It helps induce red blood cell formation. Beer contains cobalt as a foam stabilizer. Symptoms of heart failure, thyroid enlargement and neurological abnormalities sometimes occur among beer drinkers. Manganese acts as an activator of enzymes. Dietary deficiency is rare. Selenium is essential in the control of oxygen metabolism. The metal is required for the growth of human cells. Deficiency causes heart failure and muscle degeneration. Silicon plays a role in the proper formation of collagen. Fluoride is an important component of teeth and bone. It prevents formation of caries and increases mineralization of bone. Excessive intake of fluoride causes fluorosis — calcification of ligaments and tendons, weakness, weight loss, anemia, mottling of teeth (if taken during enamel formation) and brittle bones. The required amounts of vitamins and mineral salts per day for infants, children and adults are given in the table (facing page).

Ancient thought on food We have so far seen the varieties of food needed by the human body, the symptoms of deficiency, and their management. All this has been stated after thorough research, with modern investigative methods, and yet much remains to be discovered. In ancient times, such facilities were not available; yet, the concepts then prevalent have stood the test of time. Food never posed a problem in the olden days, but today it has become a source of ill health. It is said, “Do not eat until one meal has been digested.” We rarely follow this dictum. Anything in excess is poison to the body — even food and exercise. In earlier days, food was respected and this was not merely a idiosyncratic thought but one based on logical conclusions and values. Let us look at the concepts of the ancients regarding food. In the Upanishads, the sages regarded food as Brahman. What is this Brahman? The text says: “It is that from which all beings are born, they are sustained, and into it they enter when they depart.” Thus, Brahman is that from which all creation springs forth, and food was equated with Brahman. This means that from food all beings are born, and by food they are sustained and into food they enter when they depart. In short, it means that life ensues from food. However, according to modern thought, food is a sustainer of life. To understand this logic further, the Chandogya Upanishad preaches the doctrine of five fires. According to this, by the interaction of water with the earth and the heat of the sun, the rains result; by the interaction of the rain and earth, vegetation grows, which is verily food; by the interaction of the assimilated food and the psycho-physio-glandular activity, the semen in men is formed as also the ova in women; and, by the interaction of these two, life arises. Thus the theorem, life ensues from food.

Our physical body is made up of five main elements — earth, water, fire, air, and space. The element of earth connotes the quality of inertia. For example, constipation can occur even with a good diet and a healthy system. The element of water needs no elaboration; when there occurs a swelling in the body, fluid accumulates. The element of fire is energy which has the quality of consuming all that is put in, and which has a burning quality if in excess. For instance, a patient with peptic ulcer complains of hyperacidity with burning sensation. A more apt example is that of persons whose food is digested very quickly in comparison with normal parameters, and investigations reveal nothing wrong. Medical science says, ‘your system is geared like that’; but yoga says that the element of fire is working overtime in such persons and, when suitable remedies are given according to yogic concepts, relief occurs. The element of air corresponds to the production of wind in the intestines and other areas. If there is any obstruction to the passage of these natural airs, pain results; if the stomach is bloated, chest pain occurs as the nerves that innervate the chest wall also supply the stomach. The element of space or ether can be best explained by an arthritic joint where the joint space is reduced, and pain results due to altered spatial relationships between the joint surfaces. Once asanas are used to increase the joint space, relief will ensue. The body is mixed with these elements after death, and food is the interaction of these gross elements. Therefore, food is fit to be called Brahman and deserves more respect than it normally receives. In the Chandogya Upanishad, the concept of what happens to the food after it is eaten throws a new light on the physiology of digestion. It says that the food in the process of assimilation and after assimilation is divided as follows: (i) the grossest; (ii) the middling; (iii) the subtlest. The gross becomes the fecal matter, the middling becomes the flesh, and the subtlest becomes the mind. With liquid food, the gross becomes urine, the middling becomes the marrow, and the subtlest becomes speech. When nourishment is pure, the mind is clear and lucid. That is why the ancients said that the mind is made of food, and feeds on the food that it consumes. The advice to people was to avoid flesh food for it dulls the mind, and to consume only food of plant origin. Interestingly, studies have shown that athletes fed high fat, low carbohydrate diets evince significant mood alterations (Medicine and Science in Sports and Exercise [MSSE], Feb 1991). Spring et al have concluded that elderly persons on high carbohydrate diets are calm of mind (J. Psychiatr. Res. 17: pp 155-167, 1983). Just as there are three types of gunas according to yogic philosophy — sattwa, rajas and tamas — there are also three types of food. This is described in the Bhagavad Gita and are said to be preferred by three types of people. The first kind of food is pure, light, promotes longevity, is cooling to the senses, and does not cause ill health and is preferred by seekers of wisdom. The second is that selected by dynamic or rajasic people — hot, sour, excessively pungent, stimulative, astringent, dry and salty, and always bringing with it a host of diseases. The third type is liked by dull, inert persons and is stale, leftover food, half-cooked, and is very unhealthy. It is said in the texts that yoga is not for people who starve or those who eat excessively, it is for

those who eat in moderation. The Upanishads advise that one quarter of the stomach should be left unfilled. This is to promote proper digestion and comfort. However, we eat till our stomach is full and do not stop even when the body tells us that it is getting too stuffed. Flesh foods, though rich in protein content, are toxic to the human system which is not biologically geared to ingest them. A balanced vegetarian diet can give us all that we need. There is evidence that a non-vegetarian diet causes increased incidence of gall stones because of the high fat content. The chances of colon cancer, appendicitis, diabetes, joint and muscles becoming very stiff and bulky are all higher with a flesh-based diet. The body becomes rough and tough. With a vegetarian diet, the body remains soft and lustrous, yet has great inner strength. When an animal is killed, it dies in a state of stress and the body deteriorates rapidly due to the release of toxic chemicals. The flesh is damaged. It is such flesh that we consume. The very fact that it is dead shows that it is unhealthy and we eat this material as frozen food. How can man enjoy good health? When a plant is killed, such toxic changes do not take place, and, in any case, vegetables and fruit are always eaten fresh. We do not eat ‘dead’ vegetables. But we eat dead flesh. It is enough to see the hard evidence that many scientific studies have given us about the harmful effects of flesh food. There is no further room for argument, only cold facts. We do not have adequate physical activity these days and a non-vegetarian diet high in fat cannot be used by the body. The incidence of heart disease is higher in people on a flesh diet. There is a saying in ancient texts, ‘as the food, so the mind’. The mind literally feeds on the type of food that we consume. This is true. I am sure that if we see animals getting slaughtered, we will stop eating flesh foods from the very next micro-second! When the yamas and niyamas are observed, mental discipline is inculcated. Moreover, when asanas are done, certain chemical changes occur in the body which re-adjust the needs of the human physiology to a more sensitive diet. The practitioner will automatically feel the necessity for the correct diet to suit the body. Practice of pranayama stabilizes the nervous system and, in that tranquil state, the mind perceives many changes in its perspective towards various facets of life. For a yoga practitioner, diet regulation automatically occurs; for if he or she eats too much one day, the next day yogic practice suffers. In order to keep the body light, regulation of diet is essential. Today, it is the fashion to try and lose weight in the fastest way possible, and many different structured routines are followed. None will work efficiently until the fundamental discipline over the tongue has to be inculcated. Today, we are slaves of our tongue and our senses. Yoga teaches us to transcend the senses and to realize the true value of health. Food is not a means to health; it is health itself!

The Growing Years, the Aged and Yoga Life is an incessant process. Even as we age, growth continues. The moment we stop growing, mentally and physically, we reach a state of degeneration. Expansion is life and contraction is death. The majority of us become mentally rigid by the time we are in our mid-twenties. A few continue to be sensitive and alert to the changes in body and mind and such people remain young both physically and mentally. Life is a constant challenge and, unless we respond to it adequately, stress builds up. If the response is inadequate, stress accumulates and, if the problem is never solved, we suffer from diseases like insomnia, high blood pressure, asthma, and headaches. In order to achieve a balanced way of living with minimal stress, training and guidance should start right from childhood and continue for some time. Young children are very impressionable and learn quickly from what goes on around them. If they are taught the basics of healthy living in relation to all aspects of body and mind, they will carry this training into their teenage years. With further reinforcement at this stage, and with emphasis on teenage problems, they will mature as adults with well-rounded personalities. And, old age will be serene and healthy.

Children A child is mercurial by nature. If one wishes to understand what change is, it is essential to study a child with immense patience and love. A child is wholly innocent and rarely harbors anger or resentment, unless repeatedly exposed to stress. Children live in the present, with no thought of the past or future. In this sense, they are liberated. The driving force of children is their enormous curiosity, which in itself gives them the energy to do what they want. The faculty of dharana is already present in children. If this is not nurtured and developed as they grow older, their minds struggle in the process of becoming organized. Many anxious parents bring their children to me asking for some method to improve their concentration. In most of these cases, the child is normal but is not interested in humdrum everyday activities. However the child is clear about core interests. When this is nurtured and stimulated, the child automatically concentrates. It is essential to understand the needs of children and not thrust our anxieties and desires on them. Their minds are easily influenced and care must be taken to guide them in the right direction. Healthy spiritual values must be taught from a tender age. Being a medical professional, I feel that one of the

essential guidelines that should be inculcated in children is that of health. In the process, all other facets of discipline will follow suit. Parents must be role models for their children. Firstly, they must spend as much time as possible with their children. They must be involved in all their activities — their physical needs, their school work, taking part in their games and hobbies, and helping to solve their worries and problems. In short, the atmosphere in which children grow up must be that of love and care. In such an atmosphere, children will easily imbibe the core principles of honesty, love for fellow beings, giving and sharing, respect for nature, non-violence, regard and affection for elders, and discipline of body and mind. All this can be achieved only by parental commitment and example. Parental guidance is needed till such time the child is old enough to make intelligent decisions. Peer pressure plays an important role in children’s lives. However much they imbibe from their parents, they are influenced to a great deal by their friends. It is, therefore, important that children are amidst right company. It may not be possible for parents to personally know their children’s companions at school and in the playground. However when correct attitudes are inculcated children will choose “proper” friends. Child health The most important feature contributing to a child’s health is food. Unfortunately today, children have very poor eating habits. Children are exposed to fast-foods more than ever before. Eating has become a pastime, and the effects of constantly indulging in popcorn, French fries, milk shakes and ice creams are very noticeable. Even children suffer from excess cholesterol, due to the high fat content of junk food. Unless this is rectified, the ground for metabolic diseases is set in early childhood. Yet another dire habit is that of chewing gum. This is very injurious to health. The moment the digestive system senses the presence of food in the mouth, the juices in the stomach start flowing. As no food reaches the stomach, the acid outflow is wasted. This kind of ‘false alarm’ harms the sensitivity of the digestive system. Snacking in moderation does no harm. Many parents encourage their children to eat non-vegetarian food in the mistaken belief that vegetable foods lack protein. As discussed in the previous chapter, flesh foods are harmful to the body. A judicious combination of different kinds of plant foods can ensure healthy growth. Children often maintain poor posture. The sloppy posture adopted during reading or writing continues into their teens. An in-built resistance has begun by the time correction is instituted. Children also develop awkward gaits. Right from a tender age, children should be taught the right posture to sit, stand and walk. Proper sleep habits are also very necessary for growing children. This should begin with waking up early in the morning, around 5:30 and going to sleep by 9 to 9:30 p.m. The most common health problems that children suffer from are recurrent cold and cough. This may be due to poor nutrition or immunity, exposure to dust and to other children from whom the infection

spreads. In such cases, there is nothing to worry about as immunity builds up as the child grows. However, if the recurrence is frequent (some children get infected three to four times a month), then corrective steps have to be taken. It is unwise to give children antibiotics all the time, for the body develops immunity to the drugs and loses all its innate capacity for resistance. It may be feared that repeated sore throats can attack the heart valves and cause rheumatic infection of the heart and other structures of the body. This happens only if the child’s immune system is very weak. The best way to activate the immune cells is to encourage the child to exercise vigorously. This stimulates better circulation in the throat and nasal areas, and a healthy quantity of T and B immune cells are flushed into these areas. The most dramatic effect can be seen when such children practice yoga. Inverted asanas like head and shoulder stand focus the immune cells in the throat and sinuses, and prevent frequent upper respiratory infections. Regularity in practice is a must. Children in developing countries have a better immune status than in the developed nations. This is due to the immune system being stimulated by frequent infections. The more sterile the atmosphere, the greater is the impact of an infection. Up to a point, it is better to allow the child to ‘rough it out’ to some extent rather than to prevent exposure. In general, the various body systems of a child function well and, unless gross neglect occurs, diseases do not pose much of a problem. If the parents are asthmatics, in all probability the child suffers too; and bronchodilator therapy is a must till the child is old enough to be taught yoga to manage the condition. After puberty, regular practice of pranayama provides great relief. The child must follow health disciplines methodically. This is particularly needed for asthmatics, as regularity of yoga practice is very important. Incorrect food habits alter the sensitivity of the digestive system. The endocrine system of the child usually does not give much trouble. The nervous system is the most active part of the child. Great care must be taken to ensure that the mind develops qualities of perseverance, stability and patience. The health of children can easily be safeguarded by introducing the practice of yoga right from the age of five. All the asanas can be practiced by children. Their bodies are flexible and the bones have not yet ossified. Instructions on precision and forcing the body into the position must be avoided. If the growth cartilage is damaged, that part remains stunted. It is incorrect to inculcate meditation to children. Meditation is the art of silencing the mind and freeing it from the clutches of the past. It teaches us to live in the present. Children always live in the present. It is the adult with all the stress in the mind who needs meditation. The moment the child is made to sit down in a corner, boredom can set in. A child’s mind is active and ever seeking new challenges. It is harmful to silence such a mind; this can result in a state of passivity which is unnecessary. It is enough to just maintain the child in contact with the stillness of meditation by inculcating quietness for very short periods. It can be a challenge to the child when asked: “Can you sit quiet for a minute?” Immediately, the child will try to maintain the maximum silence possible! Children should be made to practice yoga in groups as this brings out the best in them. The interaction with other children and the sharing of daily experiences is far more important than meditation.

Value of Patanjali’s guidelines to children Starting with the first of the yamas, non-violence, the child should have close contact with nature to learn about natural and unnatural violence. Natural violence is that without which no creature can survive. We have to kill in order to survive. Unnatural violence is that which is unprovoked, uncalled for, that which is avoidable and ethically wrong. If value based living is not taught to children at a tender age, their future lives will be compromised. Truth is a virtue that has been emphasized in the sacred texts. Many parables are told to children about the need for truth. At times, children may tend to lie to escape from tricky situations. This must be instantly corrected. The child must be encouraged to speak the truth and face the consequences, rather than lie and face further complications. Regarding the niyamas, the factor of contentment will probably be beyond the child’s intellect. When the adults in the family live a life of simplicity and tranquility, the child will automatically imbibe such values. Tapas is one niyama that every child has in abundant measure and it must be carefully nurtured and encouraged. The burning enthusiasm in a child can easily be killed by an unsympathetic adult. Self-study is not beyond the scope of children. In appropriate situations, a child can easily be taught to observe actions and the reactions evoked. If the child misbehaves in class and is reprimanded, and the parent clarifies matters, the child will be very careful the next time as rebukes will have to be avoided. Such everyday situations can be made use of to draw the child along the path of self study. The fact of the existence of a higher power around us should be firmly established in the mind of the child. This is easily done by merely observing nature and trying to fathom its mysteries. The child’s curiosity is never ending, and the question is often asked about the power behind all that is seen around us.

Teenagers There is a spurt in the maturity process, both mentally and physiologically, in the teens. The teenager is at a very capricious stage, when value systems undergo constant change, and unless a healthy physical and mental outlook on life is maintained, problems will occur. This is a time of insecurity and the necessity to prove oneself to others. It is also a stage of rebellion, when a sudden, so-called ‘independence’ takes over the mind. Keeping in mind value based education, the line of communication with the younger generation must always be kept open, providing opportunities for free and frank discussion on whatever worries them. A congenial atmosphere at home, with the entire family interested in one another’s activities and spending a lot of time together, makes for healthy relationships. The family as a social institution is breaking up in Western countries, with a consequent increase in teenage problems. This has crept into India too. Yet, our family ties are still strong and we ought to take the utmost care to maintain them. Teenagers absorb habits — both positive and negative — from their peer group. Motivated by their

comrades, and in friendly competition, they prove themselves academically in and other activities. Good companions bring out the best in them. On the other hand, undesirable company leads to habits like smoking, drinking, drug addiction, and meaningless violence. Poor upbringing, lack of monitoring, unchecked exposure to sex and violence in books and movies, and the ills of socioeconomic instability are some of the causes of wayward behavior. An important aspect of teenage life is the burgeoning relationship between the sexes. Parents should encourage a healthy friendship from childhood, so that boys and girls grow up together in a normal, natural atmosphere. By teenage, boys and girls should have learnt to regard each other as equals and not just as objects of the other sex. Teenage is a crucial stage when the future path is decided. Patanjali’s guidelines for a healthy body and mind will prove to be very useful. The fundamental good instincts of teenagers should be strengthened by parents and teachers, who must take pains to help and guide them in every way. The health of the teenager The teenager ought to be bursting with health. However, as a clinician, I notice the rising incidence of orthopedic disorders, chronic sore throats and the increasing severity of lung disorders (such as asthma) in this age group. The causes are many. One factor stands out — that of negligence. Many patients avoid attending to the problem till it reaches a certain proportion. The classic example is that of asthma. Asthma is a chronic disorder. Climatic conditions and different kinds of food are some of the main aggravating factors. It is important to obtain relief first. The regular and uninterrupted (I lay stress on this because asthma is a disorder of hypersensitivity of the lining of the bronchial tree, and attacks vary from time to time in the nature of onset and severity and frequency) practice of asanas and pranayama provides relief to the patient. Pranayama stabilizes the sympathetic nervous system and decreases the tone of the parasympathetic. This reduces the severity of the bronchospasms. Drugs used to treat this disorder work along similar lines, but repeated stimulation by drugs induces certain inertia in the cells of the body. Natural systems of stimulation or inhibition are more useful. However a drug is the only remedy in an emergency. Due to the gentle and steady action in yoga, the relief is soothing. A definite change is felt in the asthmatic after the introduction of the breathing exercises. Smoking precludes any chance of recovery. The lining of the respiratory tree is damaged and the nerves of the body made insensitive. Teenagers sport a poor posture most of the time. Added to this is lack of exercise, making the spinal and hamstring muscles very stiff. The problems of chronic low backache and slipped discs were, a decade ago, seen in the older age group of thirty-five to forty-five. Today, they are common in younger people (between 19-25 years). Unhealthy eating habits make teenagers obese, and this complicates the problem. The best method to tackle these problems is education about right posture (though this might seem elementary, it is not surprising to see a large number of educated people unaware of the basics of right posture) and back care. This means practicing asanas on a regular basis. If practice is suspended, the problem will recur, as the body inevitably stiffens over the years.

Pain in the neck accompanied by a radiating pain in the shoulders and arms, is also common in teenagers. This is due to faulty habits of sleeping with two pillows, slouching in the bed with the chin pushed into the chest, slouching in the chair when reading, hunching at the desk — in short, bad posture at all times. The first step is to recognize where one errs. The next is exercise. If the cervical muscles are stiff, then exercise to loosen the relevant areas is a must. In addition, the thoracic (dorsal) region is also deformed. This requires twisting and back bending postures to abolish the hunch. The minimum time needed for these exercises is around thirty minutes every day. If the cervical and dorsal muscles are flexible and yet pain occurs, all that is required is a conscious awareness of posture. The patient often notices that the pain is less when the posture is better aligned. It is good policy to maintain the flexibility of the entire body by regularly practicing a group of exercises, rather than waiting for troubles to start. Back bends are highly useful to remove deformity in the cervical and dorsal spine. Even one back bend (Urdhva Dhanurasana) regularly practised, keeps the entire dorsal spine healthy. If the teenager is very stiff, the props available ensure that flexibility is obtained in a short time and with accuracy. The use of the ropes for back bends is essential. Chairs and the horse prop for Setu Bandha Sarvangasana are also valuable for relieving deformities in the dorsal spine. Stiff and painful knee joints are aggravated by faulty alignment of the foot when walking or standing. The habit of turning the foot outwards stresses the inner side of the knee excessively, medial ligament pain occurs. The cartilage is also pressurized more on one side, leading to premature and uneven wear and tear. Standing poses are invaluable to correct this. They strengthen and align the knee and the associated structures. Depending on the time available, a few postures must be practised every day. Most teenagers cannot sit on the ground and this is due to stiff knees, stiff groin muscles and a stiff lower back. Baddha Konasana, Upavishta Konasana, Samakonasana, Hanumanasana are useful to make the groin muscles supple. Malasana, Pasasana and seated twists are helpful to ensure flexibility of the lower back. Malasana is particularly good for suppleness of the groin and the sacro-iliac muscles and ligaments. Virasana, Padmasana and Supta Virasana help to keep the knees supple. Allergic sneezing disorders are very common in the teenager. These are often combined with a background of recurrent sore throats. Usually, there is a family history of allergy. Anti-histamines relieve the condition temporarily. Practice of asanas stabilizes the blood flow to the nasal lining and pools a large number of immune cells in this area. This, when combined with regularization of the sympathetic and parasympathetic nervous systems, abolishes the disorder. Practice has to be continued even after the problem disappears. Smoking, excessive consumption of soft drinks and ice creams have to be curtailed till the condition is under control. Inverted asanas such as head and shoulder stand with half Halasana are most useful here. Practice of these asanas just before retiring to bed may be helpful (an early meal is mandatory to do this). Menarche produces both physiological and mental change. Girls should be encouraged to develop a healthy outlook towards their menstrual cycle. Dysmenorrhea and pre-menstrual tension is greater among teenagers who are uncomfortable with the menstrual cycle as part of their physiology. They often get addicted to pain killers and even consume them in apprehension of pain. A healthier solution

is to practice specific asanas on a regular basis. These will relieve abdominal cramps and low back pain if done when the pain is present. The common problem of dysmenorrhea (with low back or abdominal pain) may last; in some cases till pregnancy occurs (stoppage then occurs owing to hormonal reasons). This is dealt with in the chapter on dysmenorrhea. Baddha Konasana and concave Uttanasana, Upavishta Konasana, concave Prasarita Padottanasana, will help. Inverted asanas and back bends are also valuable to abort excessive discharge and congestion in the uterus. Avoidance of stale, overcooked and excessively stimulative foods is essential in a healthy diet (free of preservatives). In addition practice of asanas is needed. It is important that the teenager takes care to maintain certain codes of conduct. Lack of proper parental guidance at this stage may result in problems of interaction with the opposite sex leading to teenage pregnancies, the incidence of which is steadily rising. The spread of AIDS is another cause for concern. Counseling is the most important method of managing problems at this stage. In spite of anti-drug programs, drug addiction is on the rise. An inner insecurity and the search for peace compel the person to escape into a world which appears to offer psychological security. Yoga is very valuable to the addict. Both mentally and physiologically, the guidelines of Patanjali and the asana-pranayama complex turn the biochemical processes of the cells towards the healthy side. The addict may be depressed or excitable. Depending on this, the asana practice differs. If the excitable addict practices forward bends, the nervous system is soothed. For the depressed addict, with a lot of inertia in the body and mind, asana practice should be dynamic and fast. The practice of Viparita Chakrasana stimulates the nervous system excellently. Detoxification of the system with medication is useful only up to a point. Unless the component of exercise is added, the hormonal change needed to correct the imbalance brought about by narcotics does not occur. The common misconception is that meditation is useful to the addict. As meditation silences the mind, the addict can be pushed into an altered state of consciousness which is undesirable. The mind must first be brought to the ‘stressful’ pattern of a “normal” person’s mind. This is healthy stress. From this level, the patient can be elevated to a higher state of stabilization. Following the guidelines of Patanjali will ensure all round development of the individual. Today, the teenager’s mind is distracted in many ways and it is essential that all steps are taken to build a fearless, upright human being. If the mature citizen of the future is to be healthy physiologically, psychologically and spiritually, the foundation should be laid at the level of the child and the teenager.

The older generation Aging is inevitable. The aging body cannot function as well as that of youth. In spite of tremendous advances in the field of medicine, man does not have control over his aging process. Even people who have been healthy all their lives find that their bodies display a slow deterioration. The physiological changes due to aging are explained in detail in the chapter on exercise. The science of yoga has a special advantage in that it can delay the aging process. Of course, any

exercise can delay this as the cells are maintained at peak performance. But other systems exhaust the cellular reserves, while yoga energizes the body without disturbance. Yoga is cellular quieting, while other exercises are cellular ‘noise’. The massage of internal organs that occurs in yoga is invaluable to the aged in certain clinical conditions. Other systems of exercises, while improving the overall circulation, do not have the same effect on the inner organs of the body; only the cells can be toned up. Aging is not just physical. It is psychological too. It is not necessary to be physically old for the mind to become weak, infirm and worn down. According to yoga, if a person’s manner of thinking has become rigid and inflexible, aging has already begun. The wise man adapts to varying situations, as the bamboo tree bends with the wind. It is the oak tree which remains inflexible and prone to damage. Aging affects only the body says yoga; it does not affect the inner self. The sutras of Patanjali highlights this. The self does not age if the manner of living in the world is such that sorrow is eliminated and the real purpose of life is understood. Even that aging of the body can be prevented to a great extent by the practice of asanas and pranayama which is the precise reason for which the science was given to us. As one grows older, one succumbs to all sorts of fears. The fear of death is, perhaps, predominant. While realizing that death is inevitable, the geriatric worries that illnesses may plague life in the last years. The rising cost of medical care is a major anxiety. Birth is not in our hands, as death is not. To a great extent, the period of life in between is in our control. The regular practice of yoga will give the confidence that physical health can be maintained till the very end. Consequently, it is not only therapeutic but also very cost effective. There are other fears too — of financial insecurity; of losing status, power and privilege; of being considered a burden by one’s children; of having to be dependent, physically and emotionally on others; of not being able to contribute meaningfully any more to society and, therefore, of being useless; and so it goes. What the older person needs is a tremendous amount of will power. An inner detachment is essential, and so is the development of equanimity and poise, to be able to cope wisely with the definitive changes in life. The Yoga Vasishta counsels: “He is called a great enjoyer who regards old age, death, adversity, sovereignty and also poverty as quite agreeable.” (Samvid, op.cit., 2390) Growing old gracefully is an art, an art that can be practiced effortlessly with the help of yoga.

Geriatric health The body becomes delicate and fragile with age. Greater care is needed to ensure good health. If we consider the health problems of the elderly, system by system, we shall have a clear understanding of the role of yoga in their lives. The heart and circulation With age, circulation declines. The arteries become stiff and inelastic. This raises systemic blood pressure, often dismissed as ‘natural for the age’. This is erroneous, for it is meant to remain at an optimum level. The systolic pressure often rises more than the diastolic. The coronary arteries, the aorta, the cerebral and many of the peripheral arteries become calcified, hampering healthy blood

flow. The aged are particularly prone to poor circulation of fluid in the lower limbs. Venous and lymphatic return is impaired due to poor muscle tone. The entire circulatory system, which is nothing but a series of well organized pipes, collects ‘moss’ on the walls — cholesterol plaque. Proper exercise prevents this change. The hardening of the arteries is arrested by the massaging action of the asanas. Essential hypertension is prevented; as the arteries are soft and elastic, circulation is maintained throughout the body. In many elderly people, the skin has an unhealthy gloss. The moment one exercises, the color of the skin changes and the gloss disappears. If one does not exercise regularly, the peripheral blood flow is diminished. The capillaries dwindle in number and the tissues do not get as much oxygen as they need. This leads to poor muscle functioning and lack of cellular strength. As the nutrients to the tissues are carried by the blood for proper energization of the cells, a healthy dynamic circulation is essential to prevent atherosclerotic changes in the coronary and cerebral arteries. Thus, a stroke or heart attack can, to a great extent, be averted. The pumping capacity of the heart dwindles with age. This leads to poor peripheral circulation, poor venous return and, in turn, a poor cardiac output. If the blood vessels are the pathways for nutrient distribution, the heart is the pumping station. The nerves and blood vessels have to be kept at peak health. Drugs can be used to treat cardiac ailments of the geriatric, but it is essential to attempt to discontinue them if the clinical situation permits and switch over to a naturally invigorating method. It is often thought that walking is good exercise for an older person. This is a misconception. Flexibility programs with proper weight bearing are more important for the health of the joints and muscles. Yoga helps the circulatory system more efficiently that walking. The benefits of the head stand, which is very essential, can never be achieved by walking. The sympathetic tone is not raised; sudden heart attacks can be avoided. Yet, the blood flow to any part of the body can be improved without strain. Though many exercises improve the overall blood supply in the body, the massaging action of the internal organs is the major advantage in yoga. The cardiac nerves are not irritated by yoga. Hence yoga is the ideal exercise for the geriatric.

Setu Bandha Sarvangasana. The pillows support the cardiac spine, resting the heart. The head is supported to avoid strain to the circulation in the head and neck area.

Standing poses improve the quality of blood and fluid status in the legs. If the person is very weak, such poses can be practised in a supine or prone manner. Gradually, inverted poses like Viparita Karani and Viparita Dandasana on the rack can be introduced. Head stand and shoulder stand, (with support if necessary), are valuable to tone up the arterial and venous systems of the entire body. The individual condition of the person should determine the need for props. Back bending asanas — like Urdhva Dhanurasana on the stool, Viparita Dandasana, Setu Bandha Sarvangasana on the box — tone up the heart. Adho Mukha Svanasana on the rope helps to make a beginning in the inverted poses. This is used in conjunction with Uttanasana and Prasarita Padottanasana with the head resting on the stool. Specific asanas tone up the circulation to the brain and improve the return of blood from the abdominal organs to the heart. At this point, it must be stressed that the use of props is the single distinct advantage that the system of ‘Iyengar yoga’ offers. It has provided a very effective way to practice every pose without strain or error, and has thus carved for itself a special niche in the field of the medical applications of yoga. Though it may be possible for the geriatric to practise a few simple asanas without the help of props, the advantage of practising the more beneficial asanas, like Setu Bandha Sarvangasana, on pillows is immeasurable (see left). Viparita Dandasana, head stand, and Urdhva Dhanurasana are effective only with props. The lungs In a geriatric person, the chest is sunk, the rib spaces crowded, the muscles at the root of the neck in front are wasted, and the abdominal organs sag forward. In this situation, the lungs cannot function efficiently. The intercostal muscles are stiff and the diaphragm does not move efficiently. The vital capacity of the lungs can only be maintained with regular exercise and, for this, back bending asanas on the props are invaluable. These poses increase the blood flow to the lungs and improve oxygen supply. They also soften the cells of the lungs and help them regain elasticity, thus improving their ‘bellows’ action. Ventilation and perfusion of gases are improved and the vital energy of the

practitioner rises. The renewed energy brightens and increases vigor, and the difference in the face after a few weeks of practice is easily noticeable. The lungs draw in energy, similar to magnets attracting iron filings. The practice of asanas retains this capacity of the lungs. Apart from back bends which are the most important for the lung, inverted asanas, twisting poses, forward bends and standing poses are very necessary to tone up all parts of the lungs. A wall can be used for twisting poses, thus enabling the practice of Bharadwajasana and Marichyasana. These poses squeeze the lungs, increasing their softness and contractibility. By massaging them, the capacity to take in blood from the lower and upper parts of the body through the great veins is maintained. This ensures healthy venous return. Problems like bronchitis and pneumonia are more common at this age due to diminished immune status. Even with antibiotics, the infections take longer than usual to clear. Senile emphysema (another aging disorder) which is due to loss of elasticity of the alveoli reduces the vital capacity of the lungs. It is important to exercise the lungs and thereby maintain the health of the immune system in that area and throughout the body. Asanas tone up the gross body and help the lungs to function properly. A healthy circulatory system provides immune cells to all parts of the body. Pranayama completes the job in a two-fold manner. It ensures an abundant intake of oxygen and healthy excretion of carbon dioxide, so that the inner vital strength is enhanced. It also boosts the immune status by improving the microcirculation in the lungs. Stress reduction strengthens the immune system, and the net result is lungs which are more healthy to fight infection. The digestive system Poor absorption of food and inadequate elimination of waste matter are some of the most frequent disorders. For good absorption, the first step is proper churning of food in the stomach. However aging reduces the effective functioning of muscles layers of the stomach, (the churning action is ineffective). Gastric acid flow reduces with age and chances of bacterial contamination increase (normally, the stomach medium is sterile as the acid kills any bacteria). The glandular secretions from the pancreas and gall bladder are not in the pink of function. This impairs breakdown of ingested food and fat absorption. The intestinal cells become ‘dehydrated’. A gradual reduction in blood flow to the lining of the intestine renders such areas unhealthy. This, in turn, affects the physiological functions of the cells hampering proper peristalsis. The nerves need fresh blood and oxygen. The sphincters of the anal canal and the bladder may be weak and excretion is affected. To ensure health of the esophagus, stomach, pancreas and gall bladder, the blood flow to these organs has to be vitalized and the nerves innervating them have to be invigorated by proper intra-abdominal massage. The reflexes of the entire digestive system are based on a complex neuro-endocrine-psychological mechanism. Practice of asanas maintains the sensitive feedback mechanisms of all these systems, so that the whole digestive network can last a lifetime. Evidence is mounting to confirm that regular

physical exercise protects a person from colon cancer. Habitual exercise is known to shorten colonic transit time of waste matter, thus minimizing contact of carcinogenic agents in fecal matter with the cells of the intestinal wall. Asanas directly massage the intestines, promoting a more complete excretion of fecal matter. Standing poses gently stimulate the abdominal organs, lifting them into the proper place and strengthening the walls of the organs. Inverted asanas do the same in a superior manner and maintain the healthy feedback functions of the endocrine glands in relation to the digestive system. Twisting poses squeeze the abdominal organs alternately, and the massage keeps the cells soft and supple. Forward bends also massage the intra-abdominal organs, but in a different manner. Hunger pangs increase with these poses; this will be very useful to the elderly who often suffer from loss of appetite. The problem of poor acid secretion is avoided by regular practice of these poses. The churning action of the stomach is enhanced. The esophagus is stimulated by twisting poses and back bends. Back bends create a feeling of satiety in the abdominal organs and control indigestion, as the stretch improves blood supply to the stimulated organs. The role of diet in maintaining the health of the entire digestive tract cannot be overemphasized. Toxic agents present in food — preservatives, radioactive material, hormones, antibiotics, pesticides — damage the pancreas, liver and the intestinal wall. The food should be simple, not too rich, prepared without much fuss, and in an easily digestible form. The most important dietary consideration for the geriatric is an adequate amount of fiber in the diet. Constipation is mostly due to lack of dietary fiber. If non-vegetarian food is avoided, dependency on plant food will provide enough fiber. It is also easier on the system as one ages. The digestive system is the key to a healthy availability of nutrients to the other parts of the body. Loss of its vigorous function results in the poor functioning of the entire body. All this can be avoided by proper diet and regular exercise. Yoga works at the cellular level with greater finesse than other exercises, due to the difference in the nature of the stimulus, the method of application, and the control of the mind in the process. The kidneys and associated structures The blood flow in the renal arteries reduces with age. This affects the filtration process. The arteries become stiff. Certain hormonal changes which create the base for high blood pressure are thus produced. The muscles of the bladder and the ureter become hypotonic and proper pumping of urine to the bladder, and excretion thereafter, become difficult. In men, the prostate gland enlarges and presses the urethra, creating outflow obstruction. Prostatectomy may be needed for benign enlargement of the prostate. Exercise is known to inhibit benign prostatic enlargement as testosterone is used by exercising muscles. Normally, testosterone is converted in the prostate to di-hydrotestosterone which plays a role in prostatic enlargement. In women, lack of estrogen creates problems of weak urinary sphincters, and prolapse of the bladder is not uncommon. Asanas massage the prostate; forward bends like Ardha Baddha Padma Paschimottanasana, are invaluable in creating a physiological pressure on the prostate, reducing the changes of easy

enlargement. Twisting poses like Marichyasana, with the foot placed on the pelvic area, are also helpful. Asanas are valuable even after a certain degree of enlargement has occurred. Baddha and Upavishta Konasana, Setu Bandha Sarvangasana and back bends are useful. Standing poses vitalize the floor of the bladder. Inversions lift the floor of the pelvic organs, strengthening them, decongesting the prostate and the renal artery, and regulating any disorder of blood flow. Back bends squeeze the kidneys and maintain cellular health. The renal artery does not degenerate. They also tone up the muscles at the floor of the bladder and the uterus, and prevent prolapse in women. Baddha Konasana and the supta variation, Upavishta Konasana and concave forward bends are very useful in keeping the pelvic organs healthy. In women, the problem of stress incontinence never occurs if the required asanas are practiced regularly. The basic change with aging, in all these organs, is one of cellular atrophy, and exercises effectively maintain their working. The role of diet in preserving kidney functions is important; a non-vegetarian diet places a heavy load on the kidneys due to the high protein content. Over the years, this can lead to early degeneration of the kidneys, with a higher incidence of elevated blood pressure. Caution and prudence in diet, and awareness of the changes in the body, will help the geriatric to preserve the renal system. The glandular system In the aged, the endocrine system does not function efficiently enough. Though the glands continue to work, the person feels less energetic; this is in conjunction with many other factors like diet and poor functioning of the nervous system. The basic drive for the endocrine glands is the chemical drive from the brain and its innumerable connections. If the nervous system is healthy, the glands also function properly. The drive from the pituitary gland to the thyroid is weaker as a person ages. The cells of the parathyroid gland atrophy, affecting healthy calcium metabolism. The atrophy of the adrenal cells results in a lower energy level. The pancreatic islet cells reduce in number and the geriatric cannot handle a load of glucose efficiently. In women, the ovaries atrophy and menopause occurs, creating secondary problems like osteoporosis and muscle degeneration. As the glands do not function healthily, the metabolic processes of the body are dulled. Poor regulation of blood glucose, fat and protein lead to problems like wasting of the tissues of the body, poor absorption of calcium, and inadequate metabolism of vitamin D due to poor skin blood flow. The resting temperature changes as the basal metabolic rate of the body is on the lower side of normal. As the glandular system is connected to the nervous system, energy levels are also affected. In short, the entire glandular system is less efficient, and the person feels listless and lethargic. All these parameters can be maintained with a healthy diet and an hour of exercise every day. Yoga is the ideal way to gently stimulate the inner organs. If yoga is practiced from a young age, senile degeneration of the pituitary gland is attenuated as the vessels do not turn atherosclerotic. This, in turn, preserves healthy stimulation and feedback to and from the other endocrine glands. Sarvangasana squeezes the thyroid and ensures its healthy functioning. It may be stated that the pressure may help prevention of benign growths. However research will shed more light.

Twisting poses squeeze the pancreas, and the islet cells continue to derive optimum blood flow from the practice of back bends. The arterial tone in the abdominal region is more relaxed. Back bends stimulate the connections of the nerves with the glandular system. In yogic exercises, the basal parameters of all hormones remain the same even after an hour’s practice; yet, the system is energized. The endocrine system is well maintained, and older practitioners of yoga are highly energetic, when compared to others in their age group. The nervous system No other system is as susceptible to the effect of aging as the nervous system. Neuronal loss is common. In clinical practice, bilateral cerebral atrophy is often ignored as being age-related. This should and can be prevented. The condition is due to reduction in blood supply to the brain. The practice of asanas maintains the cerebral blood flow. Inversions are valuable for preventing strokes. The fresh blood and oxygen prevent degeneration in the neurons. The elderly suffer from postural hypotension which is due to an inability of the nerves to regulate the blood pressure and vascular tone with change in posture. Giddiness is the resultant problem. Loss of cells leads to diminishing effectiveness of intellectual functions, thought processes and reflexes. The chemical transmission of impulses in the brain is not as forceful as before. The consistency of the peripheral nerves alters, making electrical transmissions less vigorous. The normal protective reflexes of the body slow down. Again, the brain and its connections are well preserved by inverted poses. Senile dementia (a condition of altered mental state where intellectual functions are affected and the person suffers sudden emotional bouts followed by stable functioning) and loss of memory do not occur if cerebral perfusion is maintained by inverted poses. Poor socializing, low self esteem, strained relationships (within or outside the family) can occur. Yoga helps instill greater self-confidence and enthusiasm. Much medical expenditure will also be saved in the process. All asanas are useful to tone the nervous system, particularly inversions, like the dog pose with rope, which are meant for the brain. Props help. Motor and sensory functions and regulatory reflexes of the vascular and other organs of the entire nervous system are well preserved. Fine functions like touch, tactile sensation and vibratory sense are preserved. Standing poses aid neuro-muscular coordination so that balance, grace and agility are maintained. Forward bends preserve the sympathetic nervous system. Back bends maintain the auto-energisation capacity of the body. Relaxing asanas like Viparita Karani and Viparita Dandasana on the rack help tone up the nervous system without strain.

Dog pose with rope. The head is supported by a pillow to prevent strain on the cerebral circulation; the entire weight of the body is taken by the rope so that the person does not have to strain to hold the pose and the benefits are obtained easily and quickly.

The immune system The immune status declines with aging, primarily because the circulation of body fluids is not as healthy as before. Unless immune cells are in active circulation, defense mechanisms cannot be healthy. Soldiers sleeping in the barracks are of no use. Likewise, immune cells can get sequestered in the tissues. The spleen does not function as well as in youth. The bone marrow turns senile and atrophies. The production of immune cells decreases in quantity and quality. Moreover, in the site of infection, it is not only the presence of immune cells that is important, but a certain inner vital life force which is weaker in aged persons. Add to this a poor dietary status, lack of exercise and an unhealthy lifestyle, and one can well imagine the condition of the immune system. The first step is to ensure a good diet. The next is to have a daily schedule of exercise, preferably yoga, as it is ‘nourishing’ to the body of the aged. The moment exercise is begun, the immune status improves as the circulation is enhanced, and the bone marrow is pumped with fresh blood that ensures healthy cell production. The effects last for a few hours in the post-exercise period. All asanas are needed, practiced with or without props. The massaging action of asanas works on the spleen and the body tissues, pushing the immune cells into active circulation. The longer the exercise duration — at least one hour a day — the greater is the benefit to the system. Since yoga refreshes and removes stress from the body, the immune system functions better.

The joints, muscles and bones The geriatric person commonly suffers from osteoarthritis and other degenerative joint conditions in the foot, knee, hip, shoulder, spine and neck. Most of this is due to under usage, excessive wear and tear, and wrong use. Due to osteoporosis and faulty gait, hip fractures are common, especially in postmenopausal women. Following a fracture the person is often confined to bed for many weeks; and, on returning to normal, walking and other activities become difficult. The fracture occasionally proves to be terminal in bringing with it the ills of confinement — stagnation of the secretions in the lungs, and consequent infection. The weak immune state debilitates the person further. Walking is often slow. The spine is bent forward and the gait is clumsy. The muscles are wasted and exercise capacity is poor. The blood vessels in the muscles are deficient and unhealthy. Mitochondria (the power house of a cell) are diminished in number, hence cellular energisation capacity is low. Aerobic capacity of the muscles is poor. Functions of power, flexibility, and rigidity are affected. The muscles become flaccid, with poor glycogen content. Hence the person finds it difficult to move fast. It is a notion that walking will help tone up joints and muscles. This is erroneous. The range of movement of the body while one walks is very restricted and the quality of joint and muscle toning is limited. Standing poses are invaluable for all joints which remain well toned. Since the range of movements is greater in yoga than in walking, the benefits are mechanically superior. Flexibility exercises keep muscles and joints more resilient than dynamic movements do.

The foot rest increases circulation to the calf muscles.

Standing Marichyasana. The stool helps achieve the asana in a modified manner, without strain. For the actual pose, see section on asanas for twisting poses. It is easier for the elderly to perform this asana standing.

Trikonasana with horse prop. The prop helps the aged perform the asana without strain to any part of the body.

The use of the props gives the geriatric courage to practice yoga. To maintain the suppleness of the spine, the geriatric can practise standing poses, like the Trikonasana with horse prop and the foot rest which increases circulation to the calf muscles. Twisting poses, like the standing Marichyasana with stool (see page 51), forward bends and inversions with ropes are helpful. Back bends with the rack help maintain pliancy in the anterior part of the spine. This also prevents osteoporosis and reduces the incidence of fractures. If the condition improves, patient can be weaned from the props gradually. For women, the intake of calcium, in combination with exercises, is needed to prevent osteoporosis; calcium supplementation should be continued throughout life. The bones remain healthy with exercise and density is maintained. This is due to the calculated load on the bones during asana practice. The skin Microcirculation is reduced, affecting normal functioning of the sweat and sebaceous glands. This leads to decreased sweating and increased dryness. Scaling of the skin and irritation with weeping occur. Geographical location is an important factor. Many persons tend to use moisturizing lotions in an effort to maintain the softness of the skin, especially if they live in an area prone to severe winters. One of the best methods is a massage and bath with coconut or sesame (gingelly) oil once a week. This is very common in India. It opens the blocked pores and promotes excretion of cellular debris. The use of warm water to wash the oil, along with a substance known as shikakai (similar to soapberries), massages the skin and keeps it

glowing for several hours. If this is adopted in cold countries during winter, the skin would remain healthy. Standing poses maintain the elasticity of the skin of the lower limbs and spine. While observing a person who has practised yoga regularly for many years, the very first feature noticed is the glowing health of the skin. Inverted asanas are highly useful to keep all tissues, (particularly the facial), extremely healthy. The constant soaking of the skin with blood prevents drying. Twisting poses keep the skin soft and supple due to torsion effect on the tissues. Forward bends preserve the softness of the skin on the posterior aspect of the spine, the legs and soles. Back bends do the same for the front of the body. Both sets of poses help maintain elasticity of the skin by their squeezing action. No part of the skin is neglected. Even that of the eyelid is attended to by inversions, forward and back bends. Depending on the asana, the area of the skin is made soft and supple and the health of all the layers maintained. So long as the skin is soft and vascular, symptoms of dryness, itching and scaling never occur. One can avoid facelifts if skin tone is maintained. Of course, if the sagging of tissue is cosmetically unappealing, the advantage of plastic surgery is available. Repeated surgery damages the skin and is not advisable. We should gracefully accept the inevitable effects of aging. Pranayama is highly useful to the geriatric person as it revitalizes the nervous system by the induced hibernation of consciousness, bringing with it abundant energy. It disconnects the mind from the contact of the senses, and such introspection provides tranquility to the aged. Pranayama may initially be done in a supine position with pillows for the dorsal spine, so that there will be minimal strain to the heart and circulation, and fluctuations in blood pressure cannot occur. Later, the person can practice in the seated position. The most important benefit of pranayama to the aged is normalization of the nervous system from its state of hypo-functioning. Great energy flows into the practitioner, as pranayama works on the inner vital body.

What the older generation can learn from Patanjali? If the yamas and niyamas are strictly observed, life will be comfortable for the elderly. The niyamas find a more prominent application than the yamas at this stage. Contentment is essential with age. The Yoga Vasishta says: “The wise man enjoys the entire collection of objects obtained without effort, sportively, with a mind that is unattached, as the eye experiences light.” (Samvid, op.cit., 2384) Yet another saying in the text is: “Desire is the unique jewel casket of the pains of old age and death. It is always the intoxicated player of the sports of mental and physical ailments.” (ibid., 1970) Freedom from desires is a hallmark of the wise man. Saucha is followed by everyone on a physical level. Few follow this principle to a depth which requires cleansing the inner organs. This is especially important for the geriatric, as it is difficult to pinpoint the exact time when deterioration begins in the body. Decay in the mind is easily observed, but to feel the inner changes in the body requires a different sensitivity.

It is not true that the quality of tapas is less strong when we age. Decay in the mind can set in very early in life today, because of many influences. The geriatric person has to recognize the need for swadhyaya or self-study. We have to understand the hidden fears in the mind — fear of death, fear of losing one’s possessions, fear of being a nobody. Self-study is a constant process by which man evolves. Today, many values are lost, and it is essential to reorient ourselves. Ishwarapranidhana, or surrender to God, is of great value to the older person. Peace of mind results if matters are left to a higher power and constant worrying is removed. This does not mean a state of inertia, though. A little story explains this better: Three men were walking in the forest and were deeply engaged in discussing fate, destiny, and the role of God. Suddenly, a tiger appeared; two of them sat down quietly, saying God would take care of them and what was destined would happen. The third climbed a tree. The tiger killed the other two. The third lamented, “Alas, if they had been more practical, they would be alive.” Surrender to a higher power is essential, but human effort is also necessary. Practice of pratyahara is important to stabilize the senses as years of overuse would have irritated the nerves. Patanjali says that pratyahara withdraws the mind from external contacts and draws one to the core of being. This brings about a state of happiness far better than transient pleasures. Dharana is important to bring the mind to a focal point and prevent dissipation of energy. All of us have this faculty naturally, as when we read or drive a car. If this attention is refined and continuous, meditation is the result. The nervous system is stabilized and produces tremendous energy. Meditation is essential to come closer to the true aim of life: to understand the meaning of existence and the role of the human being in it. Besides clinical benefits of stress relief, it brings the mind to a level of neuro-physiological steadiness necessary for the aged. Enormous physical and mental energy is the outcome. A state of equanimity — samadhi — follows. The Yoga Vasishta says: “He is a great doer, who passing through weal and woe, does not give up his equanimity and is calm by his very nature.” (Samvid, op.cit., 2367). It also says: “He is a great doer, whose mind is quiet even in circumstances of birth, existence, and destruction, and among objects having rise and fall.” (ibid., 2368) This is the best advice for the elderly to get the most out of their lives. May God give us the strength to live in this manner.

Yoga in Professional Life Executives are people who are always so busy that they have hardly any time to attend to their health. Constant preoccupation with their work, with all that leads up to it and its various fallouts, characterizes every kind of executive — civil servants and administrators; businessmen and industrialists; professionals like doctors, lawyers, engineers, architects, accountants, bankers and corporate managers. Some travel constantly, others are desk-bound. Most keep long working hours, with family life and leisure playing secondary roles. This lifestyle is not confined to any age group. Young executives, who have just started on their careers, want to get a toehold; middle level persons are obsessed with things they still have to achieve; and the older generation refuses to give up the reins. Executives are so occupied all the time that they do not notice the ravages on the system. Only when ill health occurs do they turn to the doctor. It is common to see an executive reporting to the doctor, “Doctor, I am very healthy, I have no problem, but from time to time I get these bouts of headache which leave me exhausted.” The very statement is contradictory for, if they were healthy, no symptoms could occur. Patanjali has aptly described this situation: “Lack of proper knowledge is the source of all pains and sorrows, whether dormant, attenuated, interrupted or fully active.” (Iyengar, op.cit., “Sadhana Pada”, II.4) In cancer, for instance, unless the cellular distortions develop to a certain degree, diagnosis is not possible. Smoking is a common example that can be cited. Most smokers cough frequently, expectorating thick sputum. This indicates the disease in its embryonic stage. Yet, they ignore the signs and continue the habit, in spite of documented proof of the ill effects of nicotine. Patanjali points out that raga (attachment) and asmita (ego) are responsible for this kind of attitude that prevents a person from admitting that he or she may suffer from cancer. This is an intellectual affliction producing a physical disease (for the five afflictions according to Patanjali’s Yoga Sutras, see page 9 in the first chapter of this book). Every job has its ‘occupational hazards’. An engineer suffers from neck pain as the neck muscles are overused. The surgeon, operating for long hours could suffer leg fatigue. The traveling executive is exposed to climatic changes, different dietary factors, lack of sleep, and jet lag. The deskbound person may suffer from pain due to poor posture. To protect the body from inherent hazards, exercise is essential. For example, breathing exercises are beneficial for the executive who is forced to sit in the unhealthy, closed surroundings of an air-conditioned room.

The physical ailments of executives have very real origins in the stress of their jobs. Time schedules and deadlines have to be met, leading to frenzy of late hours to complete assignments. These, in turn, mean poor dietary and sleep habits. Personal ambitions and monetary rewards fuel this fire of having to achieve at any cost. In the course of their work, executives have to tackle a variety of problems like competition, labor unrest, finance, corruption and so on. Each one of these takes its toll on a person’s peace of mind. It is stress all the way. Our ancient seers like Shankaracharya seem to have had foreknowledge of today’s executives in their words of advice relating to proper living. In his Bhaja Govindam, Shankaracharya says: “The water drop on the lotus is extremely uncertain in its existence, so also life is unstable.” He also emphasizes the need for equanimity in a person’s life: “Take no pride in your wealth or possessions, time loots all away in a moment; let the mind therefore be fixed within ourselves to realize the true nature of existence.” A very good method to achieve equanimity and relaxation is to get away from the pressures of work every now and then. This can be done by taking impromptu breaks (for even just a weekend, though longer holidays would be much better), in peaceful and natural surroundings, with the family. Such family-oriented vacations will go a long way in reducing stress levels in all the systems of the body, and the executive can return to work a totally rejuvenated person. Women executives — increasing in numbers now — have their own special problems. A woman’s body is more likely to be damaged by stress than a man’s because of hormonal differences. Usually, the woman has the added responsibility of a homemaker. The strain of balancing both jobs often tells on her health. In some cases, nervous exhaustion and tension in interpersonal relationships result. If a woman decides against motherhood, the situation is different. Still, stress can alter the rhythm of the menstrual cycle, and pre-menstrual tension (PMT) could manifest. Retirement is something that all executives dread. Stress starts building up as the time draws near because a busy executive cannot accept leaving the stage of action. But, it does not mean that one has retired from ‘activity’; it only means that the kind of activity is different. It is time now to relax, to spend more time with the family, take part in community work and catch up with one’s hobbies and interests. A wise person learns not to hanker after the power and prestige that the job provided. On this too, Shankaracharya has something to say: “Do not take pride in your position or the men at your command; time can wash away all suddenly.” And Patanjali points out: “Self-preservation or attachment to life is the subtlest of all afflictions. It is found even in wise men.” (Iyengar, op.cit., “Sadhana Pada”, II.9) Smoking and drinking Before I discuss executive health in detail, I would like to discuss about two widely prevalent appalling habits — smoking and drinking. The basis of the claim that they relieve stress is more psychological than physiological. These two habits are the principal causes of preventable disease and premature mortality. Nicotine is a toxic alkaloid. It acts both as a stimulant and as a depressant. The smoke contains 2% to

6% of carbon monoxide. The chemicals responsible for disease are aromatic compounds, the hydrocarbons and the nitrosamines — all are proven carcinogens. The actual changes occurring inside the system after a smoke are anything but relaxing. Nicotine favors the deposition of plaques on the walls of the arteries, especially the coronary, leading to atherosclerosis and premature heart attacks. It raises the level of the so-called ‘bad cholesterol’ (see section on metabolism of lipids in the chapter, “Health and Food”). Smokers have higher perioperative mortality than non-smokers when undergoing bypass surgery. Nicotine irritates the nerves and interferes with proper transmission of electrical impulses. The irritated nerves send messages to those centers controlling the size of the blood vessels in the body to increase intra-arterial muscle tone, thus elevating blood pressure. Nicotine causes peripheral arterial disease due to inflammation of the arteries and subsequent damage. The incidence of heart attacks is higher in smokers to the tune of 60% to 70%. Because of the increased levels of carbon monoxide in the system, the bone marrow is stimulated to produce more red blood cells to make up for the lack of tissue oxygen. Renal perfusion of oxygen is affected, causing a hormonal release which stimulates the bone marrow to produce more red blood cells with an increase in its mass. Nicotine damages the delicate lining of the respiratory tree (the fine cilia), though this is habitually replaced in a healthy person. But with repeated injury, the lining is replaced by what is known as stratified squamous epithelium. This is a scaly layer that is incapable of removing cellular and other foreign particles, including bacteria and their toxins, from the upper and lower respiratory tracts. A higher susceptibility to respiratory infections (which, in fact, smokers do suffer from), is the result. Nicotine also irritates the mucous membrane of the respiratory tract, leading to over-production of mucus from the glands. This thick and viscid secretion blocks the respiratory passages, predisposing the individual to infections like chronic bronchitis, emphysema and asthma. The vital capacity of the lung is affected. Chronic cough, sputum and breathlessness are more common in smokers, as is the incidence of tuberculosis. The damage to the cells and blood vessels of the bronchial tree prevents fresh blood, (carrying immune cells), from seeping into all areas. This causes stagnation of secretions and resultant infections. The healthy saturation of fresh oxygen into hemoglobin is affected. Carbon monoxide has a high affinity for hemoglobin. It competes with oxygen for binding sites on hemoglobin, forming the highly toxic carboxy-hemoglobin. The levels of this compound are higher in smokers because of the carbon monoxide in nicotine. All the cells of the smoker’s body receive unhealthy blood. How then can they function energetically? How can there be longevity? Long standing irritation to the cells of the respiratory tract alters the very structure of the cells and has been positively proven to cause lung cancer. This unquestionable fact is directly related to the amount smoked. For those who smoke a packet of cigarettes a day, the risks are tenfold higher. The argument that not everyone who smokes gets cancer is specious. Who can predict the inner resistance of every human body — as though it works mathematically? Health does not, and cannot be, run only on statistics. Cancers of the larynx, oral cavity, esophagus, bladder, kidneys and pancreas are all associated with smoking.

The digestive tract is irritated by nicotine. The chemical lowers the pressure of the lower esophageal sphincter at the junction where it joins the stomach, and the sphincter at the junction of the stomach and the duodenum also, thus favoring reflux of acid into the esophagus. Smokers suffer from high levels of acidity. Nicotine interferes with pancreatic secretions. It increases serum levels of glucose and fatty acids, and the clotting capacity of blood by enhancing platelet aggregation. It interferes with the healing of peptic ulcers; and also increases the likelihood of recurrence. There is evidence to link nicotine with colon cancer. There is also supposition about damage to sperms and ova. Pregnancy is deeply affected by smoking, which can delay conception. Smoking impairs placental blood flow resulting in fetal growth retardation. It can cause abortion, increased complications during pregnancy and intellectual dulling of the child. Smoking also damages genetic material, and if a habitually smoking woman conceives, the baby is often of low weight. As mentioned earlier, smoking causes hypoxia (subnormal levels of oxygen in blood and tissues). The metabolic activity of the ocular lens needs a high level of oxygen. Interference with this accelerates cataract formation. Nicotine also irritates the cells of the brain, thus obstructing a healthy pattern of sleep. Restlessness is characteristic of the smoker. Consumption of alcohol often starts as a social habit. It soon becomes the done thing to signify ‘having arrived’ in social circles. Addiction is not far off. Alcohol is a molecule which can easily move through cell membranes. One gram of ethanol provides 7.1 kcal, but this is devoid of any nutrients. The most noticeable and common side effect of alcohol is on the central nervous system. Acute behavioral patterns are too well known. In addition, chronic effects include a blackout to events that occurred during drinking, and peripheral neuropathy (numbness, tingling and altered sensations in the extremities). A medical emergency known as Wernicke’s syndrome (which includes paralysis of eye movements, altered gait, a confused and apathetic mental state, and inattentiveness, indifference to surroundings, and disorientation and progressive depression of consciousness leading to death) can occur. The cause is primarily a nutritional deficiency of thiamine, which can be treated if diagnosed in time. Alcohol can also mimic any psychiatric illness. The gastrointestinal system suffers heavily. Increased acidity causes gastritis, esophagitis, interference with absorption of nutrients in the small bowel, acute or chronic pancreatitis, fatty liver, impaired production of glucose in the liver, are some of the inherent hazards. If the individual continues alcohol ingestion, irreversible changes in the liver, known as cirrhosis, and its attendant complications, are serious disorders which lead to wasting, coma and even death. Alcoholics have a high risk of cancer — ten times that of a normal person. In the haematopoietic system, alcohol causes anemia, and reduction in white blood cell (WBC) count, predisposing the individual to infections and cancer. Cardiovascular functions are compromised by alcohol which causes dilatation of blood vessels, reducing blood pressure; increase in heart rate with increase in cardiac consumption of oxygen; and

impaired cardiac contraction. Chronic ingestion raises systolic and diastolic blood pressure. The effects are mediated through the sympathetic nervous system. Heavy drinkers suffer depression of the respiratory drive in the brain and nocturnal hypoxia where the level of oxygen saturation in the body is low. Alcohol damages the testicular cells in men, and impairs sexual drive. Women suffer amenorrhea, infertility, decrease in ovarian size and abortions. Damage to the fetus is a special clinical entity known as the fetal alcohol syndrome — the fetus suffers multiple congenital anomalies. The damage to other systems includes increased levels of cortisol, muscle inflammation, alterations in calcium metabolism with increased risk of osteoporosis and fractures. More than 30 ml of absolute alcohol per day can also cause intra-ocular lens damage. A smoker’s habit directly and instantly affects others, while a drinker’s affects others indirectly. Passive smoking increases the chances of lung cancer. There is no ‘method’ to stop smoking and drinking except a strong motivation from within. This is the only sure and healthy way. All other methods are a waste of time, and one beats around the bush while the body burns inside. Those who have no will power will never give up the habit. Patanjali emphasizes this when he says: “There are differences between those who are mild, average, and keen in their practices. The goal is near for those who are supremely vigorous and intense in their practice.” (Iyengar, op.cit., “Samadhi Pada”, I.21, 22) Exercise of any nature will give an inner stimulus to curtail and eventually abolish addiction. Practice of yoga nullifies the ill effects of nicotine and alcohol, but first the habits have to be given up. One cannot practice pranayama while continuing to smoke. Executives should use all the acumen and skill they deploy in the pursuit of their professions equally in the matter of giving up these injurious habits. Advertisements for these products should be banned. Young executives should not fall into the trap of thinking that their status demands that they smoke and drink. Sadly, by the time they are ready to quit, the damage to their health has already taken place.

Executive’s health According to yoga, there are basically three types of diseases: Adhibhautika roga: diseases due to imbalance of the five elements in the body; Adidaivika roga: genetic and allergic diseases; Adhyatmika roga: self-inflicted diseases. The executive is prone to suffer from all these types of diseases. Travel with time zone changes, altered sleep patterns and varying time of food intake disturb the balance of the five elements in the body (discussed earlier in the section on food). These elements are interrelated to the nervous and glandular systems. Stress upsetting the fire element produces diseases like peptic ulcer. Poor dietary habits disturb the element of air, leading to excessive wind in the

system. Elevated blood pressure due to stress creates a constricted circulatory system which affects the element of space for the arteries. Change in time zones causes constipation (altered bio-rhythm upsets the element of earth). Arthritic joints with effusion of fluid into the joint space occur, altering the element of water and that of ether (space). Offspring may suffer from genetic disorders if parents have lived an unhealthy life. The third category of diseases (self-inflicted diseases) is the most common cause of health problems. Diseases due to mistreatment and neglect of the body and mind are on the rise, in spite of advances in medicine. Preventive health care is yet to establish itself. Let us analyze the diseases that executives are especially prone to and see how yoga can help in their prevention and cure. The muscles and joints Many executives suffer from cervical spondylitis, low backache and knee disorders. ‘Executive’ chairs (not the most ideal), extend above the head and project forward. They push the cervical spine into an awkward position. This results in loss of the normal curvature (concavity) of the neck and causes cervical spondylitis. The thoracic spine is also hunched, compressing the lungs and pressing the intercostal muscles. Premature degeneration of the thoracic spine occurs, resulting in spondylitis of the dorsal (thoracic) spine. The lumbar spine also suffers. Long hours of sitting make the lower lumbar muscles stiff. Lack of flexibility in this area leads to a chronic low back problem. The simple movement of leaning forward to brush one’s teeth ‘freezes’ the back. The problem of slipped disc begins. It is very important to use a chair that is well cushioned and absolutely straight. This suits all shapes and sizes of spines. The best prescription is to sit erect always without a back rest. However, this requires training. The kind of bed that is used is also important. It must be hard and unyielding, supporting the curvatures of the spine. Thus, the muscles retain their anatomical shape. Many mattresses are made to adapt to the curvature of the spine rather than support it. This causes stiffness of the back muscles. Sleeping on the floor is ideal, though it may not suit everyone anatomically. To ensure the health of the back, regular exercises for the entire spine and proper maintenance of posture at all times is needed. All asanas strengthen and tone the joints and muscles very well. The strain of using poorly designed chairs and mattresses is balanced by the standing poses which strengthen the lateral part of the spine and the forward bends which give maximum elasticity to flexion of the spine. One of the basic prerequisites for spinal health is to be able to bend forward easily. The horse prop (if needed) helps perform standing poses. Problems of prolapsed discs can be prevented; and if present can be treated non-surgically. In short, any mechanical disorder can be prevented or cured by asanas. Due to improper use, the bones become weak and unable to withstand much physical load. It has been found that bones that are regularly subjected to physical stress stay much healthier for a longer period. It is essential to maintain the skeletal system, as fractures in old age are frequent and very difficult to

set right. As the muscles are well elasticized, the blood vessels are soft and supple, leading to a better circulatory status. The heart and circulation High blood pressure is the most common stress-related disorder today. This is called essential hypertension, where the excessive nervous discharge from the cerebral cortex raises the tension of the arteries of the body. This resets the pressure-regulating mechanism to a higher level. Consequently, the condition may require constant drugging and, over the years, the continued exposure to stress demands increase in drug dosage. Quite often, the executive ignores the warning signals of the body and treats the problem of elevated blood pressure casually. High levels of stress increase the discharge of chemicals which block the lumen of the coronary arteries and this, when critically narrowed, results in a heart attack. The incidence of bypass surgery for blocked coronary vessels is high in the executive group, due to unhealthy lifestyles. It should be clearly understood that a bypass operation (with or without a stent) is only a temporary solution (for 8 to 10 years). The blocked artery is by-passed by the addition of a new vessel. The effects of stress and unhealthy diet continue to operate. This results in blockage of the new blood vessel too. Unless a radical change is made in living habits, there can be no permanent solution. Irregularity in the rhythm of the heart is a stress-related problem. Instead of the normal orderly spaced heart beats, one beat occurs earlier than usual. This is known as an ‘ectopic’ beat (ectopic means out of place). Due to this, the heart pauses for a few seconds. The patient perceives a thud deep in the chest and complains of palpitation. There are two types of ectopic beats — one which is worsened by any exercise, and the other benefited by proper exercise. The latter is more common. The moment exercise is begun, the rhythm changes due to the regulation of the sympathetic nervous system and its chemical drive on the heart. The common site in the heart that malfunctions in such a way is the ventricle. The patient experiences a clear rise in the frequency of these ectopic beats at times of mental stress. Drugs that are used to inhibit the transmission of the premature electrical impulse very often do not work, as the mind is more powerful. If pranayama is practiced, the profound change produced in the nervous system abolishes such electrical disturbances. This shows the link between the mind and the regulation of breath. Unhealthy habits of drinking and smoking thicken the arteries of the body, leading to elevated blood pressure. This is unresponsive to treatment unless the habit is totally stopped. Our body is the most marvelous piece of machinery ever made and can never be duplicated. Every cell has its own method and order of functioning, all of which need proper understanding and discipline. The heart and its blood vessels are the path for distribution of energy. Constant stress exhausts the cardiac nerves. How, then, can there be energy in the body and mind? Many executives work on the treadmill and the stationary bicycle in the mistaken belief that, by boosting the heart rate and pulse beat, the cardiovascular system remains healthy. This is erroneous.

Jogging is another inappropriate exercise to the already hyper-stressed system of the executive. A procedure to soothe the mind and body is needed for which yoga is ideally suited. In this quietude, the heart is energized. Common methods of exercise exhaust the system. Waste products are built up. In yoga there is no accumulation of waste products; rather, the body’s daily production of toxins and those acquired due to stress are efficiently removed. In this process, energy is built up. Yoga is ‘restful exercise’ which refreshes the body. This is precisely what the executive needs. The massaging action of the asanas on the blood vessels can prevent or reduce blockage of the arteries and maintains a healthy state of circulation even at the age of seventy-five. The greatest advantage of asanas is that any defective part of the heart and the circulatory system can be tackled, as they have a precisely directed action on the body. They tone up the circulation in the bone marrow, thus improving the supply of healthy blood cells.

Viparita Dandasana on the rack. The body is positioned on the prop in a specific manner, enabling cardio-respiratory health.

The skin is exposed to varying temperatures. Asanas maintain healthy blood flow to the skin, tone up the tissues and prevent the effects of climatic changes. Asanas improve the blood flow to different parts of the body and prevent blockages in the circulation. Thus, the heart is kept free of obstruction. Fluctuations in blood pressure are prevented, as the asanas de-stress the nerves. Several asanas are useful for cardiac toning, particularly the back bending asanas like Urdhva Dhanurasana, Viparita Dandasana (illustration on left), and Kapotasana. These can be done with props to make it easy and save time for the busy executive. Many of the props are common everyday objects and even the specialized ones can be carried around in a knockdown condition and reassembled easily. Regularity of practice can thus be maintained. (For more details on asana usage for coronary disorders, refer text on ischemic heart disease and yoga in Section IV.) The lungs It is common to see young executives (30-45 years) getting breathless while climbing a flight of stairs. The lungs need habitual conditioning as they draw in energy. This means organizing an exercise schedule and adhering to it under all circumstances. Active and passive smoking damages the lungs. Many executives develop a ‘pot belly’ which strains the lungs further. Exercises like aerobics and jogging are strenuous and need energy to be practiced. Yoga can be done even when one is tired (up to a point), and the mechanics of the asanas are so designed as to keep every cell in the lungs healthy. The lungs are well toned by asanas. Asanas hasten the excretion of smoke and other pollutants that weaken the lungs. Back bending and inverted asanas are invaluable for this purpose. Standing poses elasticize all parts of the lungs. Practice of pranayama is useful to prevent allergic disorders. Pranayama simultaneously tones up the functions of the heart and lungs. It also protects the lungs

against the harmful effects of passive smoking (refer section on physiology of pranayama). Pranayama, even more than asanas, is valuable in harnessing the large amount of energy the executive’s lifestyle needs, as it works on the mind and the senses. A minimum of a fifteen minute practice session will suffice. If more time is available, all asanas are to be done with a mixture of movements in different directions. In the chapter on lung disorders and yoga, I have explained in greater detail the role of yoga in a few respiratory ailments (see relevant chapter for illustrations of some useful asanas). The use of props for back bending asanas (which tone up the lungs to the maximum) makes practice extremely easy. Asanas can be done ‘at once’, without preliminary movements in preparation for advanced postures. The digestive and excretory system Unhealthy eating habits affect the metabolism of the body, resulting in diabetes, hypertension, and problems of weight regulation. Eating late at night affects the digestive organs as the nervous system, (which is supposed to rest), continues to regulate the flow of digestive juices. Morning headaches or indigestion is the outcome. Smoking, alcohol, and a faulty diet high in fat and protein can overload the cells of the kidneys and lead to premature deterioration. The executive is exposed to different types of food. The food may be excessively bland or spicy and pungent, full of additives and preservatives. The digestive organs have to struggle to cope with a diet quite different from habitual. If the person is a diabetic, extra care should be observed in the type of food eaten. In developing countries, the problem of hygiene crops up and care should be taken to prevent possible bacterial contamination of water and food. In advanced countries, where this type of problem has to a large extent been solved, excessive fat in the diet is the bane. If the executive does not have adequate exercise, the excess fat accumulates in the system. Constant exposure to such food results in diabetes, obesity, hypertension and coronary disorders. It is essential to adhere, as far as possible, to a diet that one is used to. For the executive, the most common problem in the digestive system is peptic ulcer. This is due to either a bacterial infection or excessive stress, promoting excessive hydrochloric acid and pepsin secretion which irritate the stomach wall and create an area of inflammation and pain. The pain is most characteristically present two hours after food in the case of ulcers in the duodenum; it is relieved by ingestion of food and antacids. In the case of gastric ulcers, the pain is worsened by food, and the patient prefers to starve. Excessive stress is definitely a generating and aggravating factor for duodenal ulcer. In gastric inflammation, causes include excessively spicy food, alcohol, and the preservatives and chemicals used by the food industry. The ingestion of alcohol and nicotine irritates and inflames the lining of the stomach wall. Drugs used to treat peptic ulcer inhibit acid secretion in the cells of the stomach. This helps healing of the ulcers but, once the treatment is discontinued, the symptoms of hyperacidity — vague pain in the stomach, a feeling of fullness, indigestion, excessive wind formation and bloating, burning pain in the

stomach, all recur within a few months. This is due to the continued stress in the life of the executive. Sometimes, acid inhibiting drugs are advised to be taken on a daily basis. As the dosage is low, side effects may be minimal; but to be dependent on a drug for many years is not healthy. It is possible to live without drugs if a lifestyle change is made. This should include enough time every day for adequate relaxation of the mind, not just by playing golf or listening to music, but by exercise which is more concrete in improving the health of the inner organs. It is very clear that acquired diabetes (for details refer text on diabetes mellitus in Section IV) is due to abuse and neglect of the body. A high calorie diet, no exercise, alcohol and smoking are the key factors that irritate the pancreas, destroy the cells and decrease the levels of insulin. The tissues of the abdominal wall have insulin receptors. This number decreases as the amount of fat in the abdominal wall increases. When obese diabetics shed weight, their diabetic control improves proportionate to the amount of weight lost. Poor physical activity prevents the utilization of excess sugar. It is well known that mental and physical stresses increase blood sugar levels. Drugs used to treat diabetes do reduce sugar levels, but unless a parameter like exercise is added, the organs are not protected against microcellular damage. The liver is affected by alcohol, even in moderate quantities. It may be argued that a small amount consumed every day does not affect the cells, but what is more important is the property of the substance consumed. A chemical is harmful even though, in small doses, the effect is not felt. Total abstinence from alcohol is needed. The gall bladder and the colon suffer if the diet is excessively high in fat, which is a known cause for colon cancer. Constant irritation of the colonic wall by spicy and pungent food creates microcellular inflammation and colitis results. To ensure a healthy bowel, the executive must stick to a simple diet that is non-irritative. As the colon is the path of excretion, it must be kept clean to ensure purity of the other systems. Toxins in the system due to improper elimination create a variety of disorders like headaches, loss of appetite, poor weight gain, dullness of mind, lethargy and insomnia. The healthier the food, the easier it is for the colon to process the waste material. The digestive organs are massaged by forward bends and twisting asanas. Healthy blood flowing in helps proper digestion. Many executives suffer from poor digestion due to hurried eating, stress, and weak cellular strength that is corrected by asana practice, particularly twistings and back bends. Supta Virasana (see page 64), which is one of the few poses that can be done after food, ensures good digestion. Twisting poses enhance absorption and digestion by massaging the intra-abdominal organs. Back bends reduce acidity and wind formation. Asanas control problems of hyperacidity by soothing the cells in the lining of the stomach. Sense control and meditation are highly valuable in preventing peptic ulcers. Stimulation of the vagus nerve causes acid secretion in the gastric cells. If the nerve is electro-physiologically quiet, secretion is lowered. Some asanas relax the vagus nerve by stretching it and acid secretion reduces. Other asanas ‘irritate’ the nerve and hunger increases. All this can be felt, even by the beginner, during the performance of the asanas and is clinically tenable.

Supta Virasana. The pillow helps the person to perform the pose. The head is raised to avoid strain to the accessory muscles of respiration in the neck. It rests the heart.

Yoga automatically corrects unhealthy eating habits, as the practitioner progressively finds that he or she prefers a simple diet and cannot tolerate very ‘rich’ food. Any tendency to diabetes is prevented as sugar is utilized properly and the pancreas is massaged by twisting poses. Due to a cellular effect, toxins are removed efficiently. The kidneys are well massaged in back bending asanas and their functions maintained. Asanas avert cellular malfunction in the kidneys, preventing hypertension. Twisting and back bends, forward bends and inversions are all valuable for this purpose. Pranayama regulates the response of the kidneys to neuro-endocrine messages from the pituitary. Twisting poses and back bends may protect the kidneys against the microcellular damage of diabetes. The arteries in the kidneys are very delicate and the action of the yogic poses is highly suited to maintaining the softness and delicacy of the structures. The intestines are stimulated and massaged so that absorption and elimination are well maintained. The liver, gall bladder and pancreas are toned up by twisting postures and toxic products are removed. Many executives drink excessively. Asanas are very useful in controlling alcoholism. When practiced regularly the body’s tolerance to alcohol is greatly reduced. Psychologically, the person loses the urge to drink. The nervous and glandular systems The nervous system is easily affected by hectic lifestyles. The central nervous system is the storehouse of energy. The brain is the controller of the circulatory status in terms of chemical discharge to the blood vessels. Frequent travel, overwork, mental tension at work, etc deplete the chemical drive. Lack of sleep overdrives the system. Low or high blood pressure is the result. Daily exercise provides extra energy to tide over the day’s strain, both mentally and physically. The nervous and glandular systems become more resilient. The hormonal discharge in the brain controls ovarian

functions in the female body. Excess stress changes the rhythm of the menstrual cycle, affects ovulation, and damages the biological functions. This damage is microcellular, taking years to heal. The executive is prone to headaches because of the stress on the organs of perception and the facial nerves. Most of these headaches are functional, due to a disorder in the electrical property of the nerves. Factors such as smoking, alcohol, keeping late nights, insufficient sleep, and high blood pressure aggravate headaches. Stress causes the nerves of the face and head to become taut resulting in headache and exhaustion results. Sometimes, chronic headaches are due to attitudinal problems. The only solution for this disorder is to incorporate exercises which calm the nerves and change one’s attitudes. It is not advisable to swallow painkillers unless the situation is really out of control. I have already mentioned about the effects of smoking on the nervous system. Alcohol, too, does not ‘relax’ the system, as is claimed. It promotes internal stress and irritation of the nerves. Addiction to alcohol leads to tremors, easy fatigue, restlessness, and irritability. The nervous system is well benefited by asanas. Yoga, as emphasized, is non-stressful. If the brain gets exhausted by overwork, half Halasana removes the fatigue (refer section on asanas). Problems of blood pressure (which have their origin in the overdrive of the brain) do not occur, as the asanas remove the stress from the electrical system, i.e., the nerves (other forms of blood pressure due to kidney failure and other factors are not being discussed here). The immune system is interrelated to the nervous system and with its strengthening, stress-related disorders like peptic ulcers do not occur. Forward bends prevent fatigue. Viparita Karani (right) is excellent for tired executives. This is done against the wall on a bolster. The use of a crepe bandage over the face is essential to refresh the facial nerves and the mind. Passive back bends and inversions with the facial bandage also relieve exhaustion. Yoga strengthens immunity, as the nerves are made strong by all asanas. Particularly useful are the forward bends as they remove the sympathetic overdrive. If the energy stored in the brain is exhausted, the autonomous nervous system (sympathetic and parasympathetic — refer chapter on nervous system) replenishes it. Men and women experience similar problems in the glandular system. In addition, women suffer disorders in the reproductive system due to high levels of stress. The most common organ to be affected is the adrenal gland which pours out the energy-giving chemicals — the steroid hormones and the catecholamines, adrenaline and noradrenaline (refer section on the endocrine system for details). Constant travel and late nights are some of the factors that alter the bio-rhythm of cortisol, which is at the highest level at 8 a.m., and lowest in the evening. Proper rest at the right time rejuvenates the cycle. It is important to retire to bed at around 10 p.m. and rise at about 5:30 a.m. Optimum recharging of energy levels is thus ensured. This applies to any time zone in the world. In the West, where the sun sets late in some areas, people stay awake longer. Under such circumstances, one has to consciously retire. Sleep is a matter of training the mind to rest. Conscious sleep is better than heavy lethargic slumber. Irregular sleeping hours make a woman’s ovulation cycle erratic. Menstrual disturbances occur frequently.

Viparita Karani. The passive manner of keeping the head below the chest refreshes the nervous system. The active pose, without the prop, should not be done when suffering fatigue.

Inverted poses refresh the endocrine glands by bathing them in fresh blood (not increased, but healthy supply). These poses prevent jet lag as extra energy is available to the mind and the brain. Head stand and Shoulder stand just before boarding a long distance flight give maximum benefit. The health of the glandular system depends on the nervine stimuli and, if the nervous system is healthy, the glands are stimulated properly. Change in diet, time zones, stress, all affect the reproductive system and the menstrual cycle, and forward bends which remove excess stress are invaluable for women. Back bends energize the system in a stimulative manner. Age-related weakening of the endocrine glands does not affect the executive who practices yoga regularly. The immune system The immune system is very vulnerable to malfunctioning. It is well known that stress affects the proper functioning of the nervous system with increased risk of infections. Lack of sleep is one of the most potent forces generating stress on the immune system, weakening the functioning of the cells. Improper diet is another cause for ill health of the immune system. High polyunsaturated fat content in the diet affects the genesis of the lymphocytes in the bone marrow. It is preferable to stick to a vegetarian diet as it is low in fat. Studies have shown that, in vegetarians, the killer cell activity of the immune system is twice that of omnivorous controls (Malter and Co., Natur.Cancer, 1989).

Emotions also affect the immune system. People who are prone to anger and who are emotionally weak suffer more from dysfunctions of the immune cells. High levels of noise are also known to affect the immune system. Nicotine and alcohol hamper the production of healthy cells in the bone marrow, and immature cells which function ineffectively are released into the circulation. A wave of stress releases large amounts of adrenaline and noradrenaline which can either stimulate or inhibit the functions of the immune system. There is a difference between healthy and unhealthy stress. The former is necessary and tones up the immune system, while the latter wears out the immune functions. Such a healthy stimulus is exercise. Unless the daily schedule includes exercise, this vital part of the body begins to suffer. Neither excessive nor insufficient exercising is good. The optimum type of stimulus strengthens the immune cells. Yoga attributes this to the principles of evolutionary protection. In other words, everything in nature will function healthily and consistently, provided the right kind of stimulus is given every day. Yoga is ideally suited to protect the immune functions, as it removes the excess overdrive of the sympathetic nervous system and the ‘noise’ of stress. All asanas are helpful. Pranayama is very valuable for the immune system. Pranayama is very important for the executive. The most obvious effects of pranayama are referable to the nervous system. As prana is all forms of energy, regulation of this is very important in preventing exhaustion. Pranayama stimulates and regulates the healthy functioning of all the organs through the nervous system. Pranayama can be described as the current inflow that feeds the battery which is the nervous system. If the car is overdriven, the system is weakened. This is the state of the executive. The facial muscles are relaxed during pranayama practice. This pacifies the organs of perception (smell, touch, sight, hearing and taste) and allows the mind to withdraw inward into relaxation. When the mind relaxes, the practitioner enters into the next stage of concentration.

How does yoga help the executive? Yoga is a way of life and not just practice of asanas and pranayama as is commonly assumed. Patanjali’s sutras cover the entire gamut of living, giving us measures by which we can get the maximum out of our lives. This does not refer to materialistic gains, but to those intangible rewards that make our lives meaningful. The executive would do well to follow the yamas and niyamas in daily life and work. Ahimsa (non-violence), satya (truth), asteya (non-stealing), brahmacharya (control of the senses), and aparigraha (non-covetousness) can all be exercised. Ahimsa is not just against physical violence, it can also apply to standards of business conduct. Advertisements detrimental to health are a travesty of satya. Cigarette companies splash their products in every media and, though advertising alcohol is banned in India, thinly veiled advertisements for it are quite common. Egos, competition, premature desire to be the best, all lead to the practice of unethical methods that go against the teachings of Patanjali. Saucha and santosa need to be practiced while the executive is committed and dedicated to work (tapas). Saucha (hygiene) goes beyond the body to the inner organs. The hyperactive executive must be aware of early signs of deterioration in health and act on it. If yoga is practiced regularly, potential

problems can be nipped in the bud. Contentment (santosa) is a state of mind. It is not the object of desire but the constant longing for more that exhausts the mind. The Yoga Vasishta says: “Not wishing for the objects of enjoyment that have not arrived, and enjoyment of those that have arrived spontaneously, is the characteristic of a wise man. He is called a great enjoyer who does not hate anything and does not long for anything, and who enjoys everything on hand.” (Samvid, op.cit., 2386, 2387) Swadhyaya or self-study is illustrated by the saying of Bhagawan Sri Sathya Sai Baba that you are actually three people — the one you think you are (a self-assumed image), the one others think you are (that which is projected), and the one you actually are (the atma within, but covered by the dust and dirt of worldly motives). Introspection of one’s own thoughts and deeds will stand the executive in good stead on many occasions. Iswarapranidhana is to do one’s job to the best of one’s ability and leave the rest to Providence. The message of the Bhagavad Gita is: “Work alone art thou entitled to, and not to its fruit.” The belief that there is a higher power that will ensure fruit to hard and honest labor is very essential, particularly in today’s world, to provide solace and equanimity to workers in any field. With the practice of the yamas and niyamas, pratyahara controls the senses and the mind. This destresses the nervous system and dissipation of energy is controlled. Dharana, dhyana and samadhi are psycho-spiritual processes which bring about steadiness of mind, and subtlety and refinement of consciousness. Complete tranquility is the result. For the executive, this can be interpreted as releasing the tensions of work and engendering a much needed state of composure and serenity. It is very clear that the executive has to create a lifestyle around healthy habits. The time has arrived for executives to take the lead, to be forceful about their health, physical and spiritual, as they would be in their work. Swatmarama, the author of Hatha Yoga Pradipika, has asserted that there is no age to practice yoga; whether one is young, old, infirm or sick, one can begin to practice yoga so that the body is made fit. The discipline of yoga in all its aspects will help the executive attain what an individual needs most in life — trikarana shuddi, which is the integration of thought, word, and deed.

Yoga for the medical professional The medical professional is no exception when it comes to suffering illness. The doctor must try to be a picture of health so that patients are inspired to follow the example. If there is the quality of purity of purpose and tremendous tapas, that very force conveys encouragement to the patient. Doctors face several occupational hazards in the pursuit of their profession. A physician has to examine patients all day. If the setting is in a private clinic, the occupation is sedentary. If the person has a hospital job, walking as an exercise is automatically present. Yet, it is important to rest and recuperate. A surgeon has to stand or sit for many hours during operations. Though the job requires stamina, it is of a sedentary nature too. Still, depending upon the kind of instruments used, the hands, neck and lower back are inappropriately strained.

Doctors are not far behind other professionals in being prone to the twin addictions — alcohol and nicotine, especially the latter. If they cannot be adequately careful with their own health, how can patients be counseled? Surely the surgeon who smokes between operations is aware that he is endangering his body. It is medical professionals who should lead the campaign to curtail smoking and not fall prey to it themselves. The practice of yogic asanas and pranayama will be of great value to doctors in combating their own health problems. It will also convince them of the therapeutic value of yoga. Let us briefly discuss the need for yoga with reference to a few systems. The heart and circulation The general principle of a sedentary life affecting the heart and retarding the circulation applies to the medical professional. It is important to set aside time for regular exercises. Otherwise, using the prop for Viparita Dandasana and the bandage around the face for a period of five minutes removes stress from the entire system. Owing to long hours of standing, the neuro-vascular system of the legs will suffer fatigue. A simple remedy is to invert the legs into Viparita Karani against the wall, followed by Supta Virasana. Time saving methods are essential for the doctor to practice yoga. The circulation to the frontal body is enhanced by the rack. Dog pose on the ropes and Uttanasana on the stool help challenge cerebral perfusion. This removes mental fatigue as the doctor expends enormous energy in analyzing case material. If time permits, all asanas can be done. The lungs As doctors may be confined either to the consultation room or the hospital premises all day, they breathe stale air. The exposure to bacterial infection is high due to patient proximity. So long as the immune system is healthy, disease is kept at bay. To protect the lungs from this, asana and pranayama are invaluable. All asanas can be used. Back bends are particularly important. Supta Virasana and the rack refresh and aerate the lungs. Toxins are removed more efficiently. Even for a smoker, the practice of yoga will protect the inner organs to some extent. Pranayama refreshes the lungs at the cellular level. It enhances clearance of toxins and infuses fresh air and energy into the practitioner. The digestive system In a hospital set-up, one is exposed to different food patterns. It is important to ensure that the food is low in fat. Proper selection of food, and a healthy exercise routine to balance the caloric intake, is essential. Irregularity in timings is another problem in a profession fraught with emergencies. As far as is practically possible, meal timings should be consistent. Back bending asanas like Supta Virasana, Poorvottanasana, Viparita Dandasana, are all helpful for indigestion. The nervous system

A doctor’s mind can be prone to excess stress. Long working hours, especially with night duty, can exhaust the system. Night duty hours should be restricted. Practice of inverted poses on the ropes and chair give relief to the strain from sleepless nights. Forward bends give extra energy to face the daily strain of long hours of work. A regular exercise schedule will go a long way in combating nervous stress. Practice of pranayama with the bandage steadies the nerves for microsurgery. This is especially useful for surgeons who are engaged in the difficult task of re-suturing torn nerves and blood vessels. Smoking, so often resorted to when the person is under stress, can be replaced by pranayama. For surgeons who suffer eye strain, Shanmukhi Mudra with the bandage and Viparita Karani are valuable. The organs of perception are taxed to the maximum in surgeons. Physicians tax the mind. Both these kinds of strain have to be neutralised by practice of pranayama and shanmukhi mudra. The muscles and joints A physician stationed in the clinic is prone to stiff lower and upper back muscles. The examination of a patient is always done from the left side of the patient, unless the doctor is left-handed. This leads to rotation of all the body muscles to one side and, in the long run, creates pain due to structural misalignment. The type of chair used has to be carefully selected. The surgeon also operates unilaterally. The hands of surgeons are used in a limited manner without an opportunity to stretch out. Gynecologists perform surgeries from the same side; if the surgery requires a vaginal approach, the body has to be bent from the lumbar and cervical to an acute angle to facilitate viewing. With the advent of microsurgery, the strain on the cervical and optical muscles is enhanced. The muscles and ligaments of the legs of a surgeon are overstrained due to excessive standing. The right leg is strained in right-handed individuals due to an unconscious habit of leaning over to the right. This is often manifested as low back pain (on the right lumbo-sacral ligament) and hypertrophy of the lateral muscles and extensors of the hip.

Supta Virasana with pillows between the thighs and calves has a massaging effect on the lower limbs.

Eye surgeons suffer severe cervical strain. The next in line are the pathologists, research workers and lab assistants who have to crane their necks into the microscope for hours at a stretch. Surgeons using the operating microscope for prolonged periods are prone to degenerative neck disease. Dentists operate from an awkward angle, and suffer from cervical and shoulder pain. The approach to the oral cavity is from one side, and this causes the spine to bend laterally and be rotated forward. To ensure health, it is essential to be aware of all such situations. The next step is to provide correction and counter movements. Depending upon the pattern of usage, either rest to the affected part or, better still, exercises which act as a form of rest — example, Supta Virasana (see page 69) — should be introduced, particularly for surgeons. To prevent cervical problems, back bends on the ropes (see page 69) are useful. This position can be held for a few minutes and repeated several times. As the cervical spine is bent forward most of the time, reversing the curvature is essential. Back bends are useful as they remove fatigue of the spinal muscles and prevent degenerative disc disease due to constant loading of the spine in the flexed position. They also invigorate the entire system and provide the necessary healthy blood circulation to the organs which are kept stationary and flexed. Standing poses are needed to promote better stability for ligaments and muscles in the legs. Inverted poses strengthen the cervical muscles.

Back bend on the ropes elastisizes shoulders.

Asanas like dog pose, Hand stand, and Urdhva Mukha Svanasana stretch the palms, forearms and upper arms. This improves blood supply to the armpit area. It also stretches the side chest area which is constantly pressed. Forward bends are valuable as they teach the right extension of the spinal muscles which remain cramped for many hours at a stretch. Rotational movements correct the effects of one-sided use of the spine. Depending on the side used frequently, the asanas have to be done with more force on the other side.

Value of yoga sutras and other guidelines for the medical profession Much can be understood about the human body by delving deep into the realms of yogic sciences. Yoga provides the answer in many inexplicable situations, but this cannot be verified by analysis in the laboratory. The sweetness of a mango has to be experienced in the eating; no amount of words can suffice to describe it. Deeper layers of functioning are yet to be accepted by modern medicine. If the study of yoga is combined with the study of modern medicine in learning about the body and mind, new dimensions of healing can be unfolded. Medicine was one of the sciences studied extensively in ancient India, and we are fortunate to have treatises like the Charaka Samhita and the Susruta Samhita, written around twelve centuries ago, still available to us. It is amazing how the values they set out for the medical profession hold good even

today. Medical professionals will benefit by the yamas and niyamas, especially as they are involved in life and death matters. This is purity from within. In the Charaka Samhita it is said that “no gift is higher than the gift of life” (Singhal, G D, Surgical Ethics in Ayurveda, “Charaka Samhita”, VI.1.461); and also that “a wise student aspiring to be a doctor should try to increase his proficiency in all aspects to the best of his ability by all possible means, so that he may be regarded as a life-giver by the patients” (ibid., I.1.133). The doctor-patient relationship is fraught with strain. Unfortunately, caught up in the fast pace of modern living, the medical profession sometimes tends to forget the deeper meanings of ahimsa, satya, gentleness and ethical behavior when dealing with patients. Patients are human beings in trouble. They have to be given the utmost care and consideration. It is essential that the patient be given enough information about the treatment so that confidence is built up and they can face the outcome with a clearer and braver attitude. That is half the battle won. Recognizing this, yoga lays a firm base of first educating the patient about the illness and explaining the guidelines to achieve health. The mental adequacy of the patient is assessed and yogic training instituted accordingly. Yoga is deeply concerned with each patient and treats each as an individual in his or her own right. The Charaka Samhita talks about this aspect of medical care, too: “Friendship, sympathy towards the sick, interest in cases according to one’s capabilities and no attachment with the patient after recovery — these are the four ethical principles of a doctor.” (Singhal, op cit., “Charaka Samhita”, I.9.26) Saucha is important both from the physical and bacteriological point of view. It is to be appreciated that, at a time when microscopes did not exist, the Susruta Samhita warns that “patients in whom there is a break in the continuity of tissues should always be protected from dangerous and invisible creatures — nisacara” (Singhal, op cit., “Susruta Samhita”, VI.60.3). Tapas is essential for the medical professional. Commitment to work includes the obligation to increase one’s knowledge. “A person who studies only one branch of science cannot arrive at proper conclusions; therefore, a physician should try to learn as many related sciences as possible.” (Singhal, op cit., “Susruta Samhita”, I.4.7) Today, it is the era of super specializations where we will shortly have doctors attending to the left or right nostril only! “In order to broaden your knowledge and outlook, you should study the subject regularly, take part in scientific debates and discussions, observe the allied sciences and take training from specialists of those branches.” (ibid., IV.28.27) Swadhyaya helps doctors understand their limitations and teaches them to value the professional opinions of colleagues. The Charaka Samhita advises: “You should increase your professional skill by learning from others without being jealous. The intelligent would regard the whole world as their teacher whereas the unintelligent would think the same as their enemy.” (Singhal, op cit., “Charaka Samhita”, III.8.14) And, “doubts can be cleared by a group of physicians” (ibid., I.25.40). This is very pertinent, indeed, to our times, when the clash of ego between medical professionals is all too common. It is the patient who suffers in the process. Medical ethics are also involved in matters like euthanasia, where the doctor must remember that emotions should have no part to play.

Dharana and dhyana and other psycho-spiritual techniques are valuable for the medical professional as they lift one to a different dimension. In simple terms, it means stress relief. In deeper terms it means bringing the person into contact with other realms of existence so that answers to seemingly impossible situations of health and disease can be easily found and healing assumes meaning in the true sense of the word. Modern medicine has been successfully challenged by situations where, as catalogued in Howard Murphet’s book, Sai Baba — Man of Miracles, cures of impossible conditions have taken place by methods that cannot be understood by science.

Yoga and Sports The word sports means an athletic game or pastime, a time when we amuse ourselves in the spirit of equanimity. It is a diversion from the humdrum of daily life. Or it could be a passion to some. Sport also gives the entire world an opportunity to mingle together, exchange values and improve relationships. Sporting events form an ideal condition for bringing the human race together. Ordinarily, most people indulge in a sporting event for the pleasure of it and also as a means of achieving fitness, to tone up their bodies and feel invigorated. This, in turn, leads to mental relaxation. However, games have also become a profession. Herein enters the idea of competition and the lure of money. Physical activity is highly beneficial to the body, as only this can produce the necessary chemical changes. However, if the very activity turns into a career, the stress can damage the body. It is, therefore, important to find solutions to the changing scene of sports. It is also essential that the sportsperson includes recreation. Yoga is an ideal method for protecting the mind and body of the athlete. The run of the mill player will find yoga useful to combat physical problems brought on by the game. The professional athlete will realize it to be an invaluable means of reaching and maintaining the peak of physical and mental strength. The first principle must be to ensure that the body is not damaged by any sport. Body movements are done without mental tension and stress relief results. However, as sport is becoming more and more professionalized, a sportsperson can suffer stress equal to or greater than an executive. The latter uses physical activity to remove physiological and psychological stress. In the case of the professional sportsperson, the right approach is to use yoga to relieve stress on the body and mind. One main concern is that most sporting activities rely on usage of certain parts of the body, and this creates asymmetry and overuse of those parts. All kinds of sporting activities are gaining ground. Extreme sports like bungee jumping are particularly strenuous and harmful to the joints of the lower limb. Many such equally harmful activities exist and the list increases every day. When ordinary sporting events are loaded with potential harm, we can understand the dangers in the newer kinds of sporting activities. A larger number of women are entering the sports arena. By pushing their bodies to the limits of training, women face potential hazards to their delicate physiology which, in the long run, could harm

genetic material. Infertility is higher among elite athletes (primary, or secondary due to drug abuse for performance enhancement). A sportsperson needs three basic qualities: speed, strength and stamina (SSS). I would add a fourth aspect— mental fortitude along the lines of Patanjali. This is not purely a physiological phenomenon, but a complex interplay of the mind and the body. Pranayama builds up endurance (both mental and physiological), courage, vital strength due to refreshment of the nervous system, and skill due to a serene mind. All the systems benefit from pranayama. The vital strength of the cardiac and respiratory systems are improved by pranayama and any sportsperson who has to move about constantly (in games like hockey, football, boxing, and swimming, golf, cycling, skiing and rowing) will benefit. For a swimmer, the various types of pranayama with the use of bandhas and kumbakhas are helpful in preventing exhaustion of the heart and lungs. During weight training, the nerves and the heart are under stress. Pranayama done on the pillows with prolonged exhalations relieves this strain. Certain quietude is needed in some events like archery, shooting and golf. Steadiness of the nerves is essential for skill in these events and pranayama, by quieting the organs of perception, provides a withdrawal. This stabilizes and steadies the electrical function of the nerves. I have discussed the need for pranayama with each sport later. The daily life of the professional sportsperson calls for systematization of the time of training and regularization in the intake of a balanced diet of protein, carbohydrates and fat. Depending on the type of sport, the training routine varies and the type of side effects on the body also varies. Many studies have been done on the metabolic, skeletal, muscular, cardiac and pulmonary changes following training.

The impact of sporting activities on the human body: The heart and the circulatory system In the cardiovascular system, the resting blood pressure and pulse rate are often lower than in nonathletes (see effect of vagal tone in nervous and glandular systems). Due to the training effect the heart is larger in size than that of a normal person. The ventricles, on account of their bulk, need to contract only a little to push out the blood. In a normal person, a complete contraction is needed. Both aerobic and anaerobic capacities are greater, and are of value in endurance events. Some studies have reported symptoms of giddiness, exhaustion and light headedness with endurance training, but this could represent a factor of overtraining. The blood is kept more fluid and fibrinolytic mechanisms are favored, which means that the tendency for clotting is less. This is also balanced by a rise in clotting mechanisms, lest the anti-clotting tide overtake the health of the body (MSSE, August 1990). Fortunately, the rate of progression of atherosclerosis is less among sportspeople, especially in the arch of the aorta where elasticity is essential to maintain coronary flow. It is clear that the circulatory status of the sportsperson is good; but, according to the science of yoga, the sportsperson has an ‘irritated’ type of circulatory status even though it may appear to function healthily. A healthy circulation is ensured by yoga in a non-irritative manner (stimulation) to the

sympathetic nervous system. It leads to a restful increase in the blood flow to different parts of the body. A special problem in the athlete is orthostatic intolerance, or the inability to stand still in one place. When we stand still, the blood pools in the vessels of the legs and the volume returning to the heart is less. Consequently, the cardiac output and blood pressure alter. In a normal person, the nervous system, in its control over the altered situation, is able to cope. In a highly trained athlete, the increase in the blood volume is several times higher than normal. This somehow alters the response of the nervous system which fails to make appropriate adjustments in the standing posture, and the athlete experiences giddiness (MSSE, June 1993). Such changes do not happen to the yogic practitioner. The nature of stimulus being different, a healthy resilience of circulatory flow is maintained. Asanas and pranayama rectify problems of circulatory maladjustment by regulating the nerves which control blood pressure. Hence, an athlete would benefit by incorporating yogic practice in the daily routine. Inverted poses, which are peculiar to the yogic system, are of special benefit to circulatory stabilization. Back bends are invaluable for cardiopulmonary, gastrointestinal and renal flow, bladder and uterus and ovaries.

Hematology The hematology varies with the type of sport practiced and the body mass of the person. The hematology of persons associated with endurance events may vary in comparison with those associated with power training (Stewart, Steel et al, Med.Jour. of Aust., 2: 1339-1343, 1972). Red cell mass is also related to lean body mass, and to height, weight and sex. Higher counts of hemoglobin and red cell mass have been found in males due to the circulating testosterone levels. Training increases the number of WBCs in circulation and studies reveal differences in the sexes, as males generally train more intensively than females due to their greater physical capacity. Differences in the kind of sport also affect the blood picture. Studies have shown that track sprinters have a higher mean hemoglobin concentration than middle and long distance runners.

The lungs The aerobic capacity is far greater than the average person. As the lungs are stimulated every day by different methods, they adapt to the strain and help perform the particular sporting activity without difficulty. This is a matter of adapting and conditioning the respiratory system to the stimulus, and the training is task specific. A sprinter will not be able to do a marathon run and vice versa. Each type of sport requires specific training, it is impossible to train the lungs for all facets of sporting activities. It is a common notion that one has to push the system to maximum aerobic capacity (to achieve proper oxygen utilization) for health of the body. This is erroneous. What is required is that the vitality of the system be retained with age. This is achieved easily by the practice of asanas, where all body functions are toned up. The lungs are toned up by the practice of back bends which give an effect similar to aerobic exercises, yet the perceived exertion while practicing the asana is different. To reiterate, the heart is kept well toned up without the adaptive changes that occur in the body of the athlete.

It might be strange for modern medicine to appreciate that the body can be toned up without the usual notion of exertion. The exertion in yoga is of a different type. The body is certainly trained to increase the intake of oxygen, but usage is curtailed at the same time, and energy levels are not exhausted but improved. All the parts of the body involved in oxygen transport to the cells are toned up to the maximum and the elasticity of the tissues is sustained. This maintains the delivery of the nutrients to the tissues even as a person ages. No doubt the oxygen usage in aerobic training is higher and the body is fitter than an untrained body, but this is at the cost of many adaptive changes. In yoga, the health of the system is maintained without any change in such parameters. Yoga is a reasonably energy conserving exercise while sports is energy exhausting in nature. Back bends create the effect of having jogged (for some time) in a short period. The expansion of the lungs is the maximum that can ever be achieved. Forward bends train the posterior surface of the lungs, while lateral bends and rotations act on other areas. Pranayama maximizes endurance, especially if the kumbhakas are properly performed. In fact, if this is done regularly, the stamina of a runner is achieved (to a degree) without actually doing it.

The digestive system It is well known that prolonged exercise training actually suppresses appetite rather than increasing it, even if an acute bout of exercise increases the appetite soon after. The role of the mind is a crucial deciding factor in this. If the mind is deeply involved in work, the person can easily forget any physiological stimulus, however intense it may be. We have all experienced this at some time or other. Any change in the body due to training is also influenced by the mind. Regarding transit times of gastric contents, studies are conflicting — while some studies have shown a shortening of transit time in well-trained bodies, others have shown an increase or no change. Ultimately, it is enough if the system is healthy, as there are many reasons for inter-observer error. With the practice of yoga, the mechanical (peristalsis) and absorptive capacities are regularized. Depending on the type of asana used, the entire digestive tract can be either stimulated or soothed. Nevertheless, the effect of endurance training will be neutralized by asana practice as balance of sympathetic and parasympathetic activity is obtained. If a person feels hungry before starting yoga practice, the hunger pangs are attenuated during the practice and reappear when the practice is over. Hunger can also be reduced or enhanced by yoga, depending on the need. This is of immense value to the sportsperson who has to maintain a fixed body weight for certain events.

The nervous and glandular systems Sports demand fast physiological responses. The mind and body are tuned to such situations. The role of the mind in improving nervous reflexes cannot be underestimated. The sympathetic nervous system is the one deeply affected by training. However, the sympathetic tone is overcome by the parasympathetic (vagal) tone with chronic training. This results in lower pulse rate and heart rate at rest. These changes revert to normalcy with deconditioning in a variable period. During exercise the athlete is able to use the sympathetic system effectively. In a normal person at

rest, there is a balance between the activity of the sympathetic and parasympathetic nervous systems. Due to constant bombardment of the nerves with high intensity stimulus of an aerobic nature, the balance is reset with a predominant vagal tone. The reflexes in a trained athlete are faster than that in a normal person, but this diminishes over a period of de-training. The sympathetic and parasympathetic nervous systems balance each other during severe exercise. However, at the end of the bout the former system is exhausted. noradrenaline and adrenaline are released by the nerves of the sympathetic system. These interact with two receptors in the blood vessels — alpha and beta. Adrenaline reacts with both types while noradrenaline with only alpha receptors. Asanas balance the activity of the autonomic system. Hence, the athlete would never suffer exhaustion that easily. Orthostatic intolerance is also prevented. As the endogenous stimulation of the body in a person is both chemical and nervine, great energy is available to the athlete who practices yoga. When fatigue occurs, practicing Viparita Karani will help in recuperation. Half Halasana is also valuable. Thus, the nerves are never allowed to get overworked (refer section on effects of asanas on the nervous system). The hormones The endocrine system is poised to respond very fast to challenging situations. There are a variety of adaptations that occur in the body of a trained sportsperson. Let us briefly study the hormonal response to exercise: Insulin Initially, the blood levels of glucose are higher to meet the needs of the exercise and diminish as the body is depleted of its store. Insulin levels also fall simultaneously. This helps minimize the use of glucose by non-active tissues and spares the energy for the active muscles. In trained individuals, the level of insulin does not fall as in untrained persons. Glucagon Glucagon is secreted by the alpha cells of the pancreas in response to the low levels of blood glucose. It has two functions — glycogenolysis and neo-glucogenesis. In prolonged exercise, the blood glucose level is maintained by glucagon (in response to diminishing levels). With insulin, this response is dampened in trained individuals. Catecholamines Muscles are a major source of adrenaline during exercise. Catecholamines are released from sympathetic nerve terminals and the adrenal medulla. In moderate exercise the levels of adrenaline and noradrenaline do not change, but in severe exercise the levels rise dramatically. Noradrenaline levels exceed adrenaline levels five fold. The release of these hormones is diminished by training.

Adrenaline stimulates glycogenolysis during exercise. It also stimulates lipolysis (mediated by the enzyme lipase). The blood levels of free fatty acids rise. The rise of adrenaline is greater in static exercises and that of noradrenaline in dynamic types. The levels of neuropeptide Y also increase during exercise and control the vascular tone in skeletal muscle. Growth hormone (GH) One of the major activators of lipolysis, growth hormone is released in response to intermittent and continuous exercise. For certain bio-chemical reasons, neural factors assume more importance with regard to GH during exercise. The magnitude of the response is related to the peak of exercise. The release of GH is pulsatile, so exercise once started should continue in a steady manner to ensure regular pulsatile release. The adrenal axis In prolonged exercise, the hypothalamus stimulates the pituitary to release the hormone ACTH. This stimulates the release of cortisol from the adrenal gland which induces proteolysis in muscles. Thus, cortisol normalizes the diminishing levels of blood glucose during exercise through breakdown of amino acids and its conversion. The thyroid hormone The hormones from the thyroid gland generally stimulate the body metabolism, rate of oxygen consumption, protein synthesis, lipolysis and glycogenolysis. The thyroid hormone acts through other hormones. The levels of thyroid hormones do not rise during exercise. The anti-diuretic hormone (ADH) Fluid and electrolyte balance during endurance activity is very important. In response to sweating, the nuclei in the hypothalamus are stimulated, and these prompt the posterior part of the pituitary to release ADH. ADH stimulates the cells of the kidneys to retain water. If dehydration occurs, the pressure in the blood vessels falls and this again provokes ADH release to retain water and increase the blood pressure. In yoga, none of the parameters change from the baseline. We begin with a certain amount of energy substrate and end with the same, but feel more energized. Yoga is useful to balance hormonal readjustments arising out of athletic training. Asanas like Head and Shoulder stand, forward bends, half Halasana and passive back bends, soothe, refresh, and invigorate the glandular system respectively (refer section on physiological effects of asanas on the glandular system). Passive forward bends and half Halasana are particularly valuable to prevent exhaustion.

Metabolism

Metabolic rate is an important factor that determines the long-term effect of endurance training. It also establishes the caloric cost of the exercise. This helps determine the nutrition needs. After maximal exercise, the oxygen consumption does not return to normal levels immediately, but in a curvilinear fashion. This extra oxygen consumption, due to the elevation of the tissue metabolic rate, has been termed the oxygen debt. During exercise, the turnover of lactic acid is several times greater than at rest. The metabolism of proteins, fats and carbohydrates depends on the hormonal responses. Endurance training has different kinds of effects on such metabolism. I have summarized them below: Protein (amino acid) metabolism High intensity training doubles the availability of amino acids, forming an important glucogenic precursor. The conversion of alanine to glucose occurs in the liver. To support prolonged exercise bouts, amino acids serve as important fuel bases. It appears that they may contribute as much as 5% to 10% of the source of fuel for muscle contraction during a marathon race. It is well known that heavy exercise induces a greater loss of protein through the kidneys (proteinuria). This is reversible and represents a direct increase in permeability in the cells of the tubules. Fat metabolism Lipid is a primary source of energy for prolonged high intensity aerobic activities. In short workouts, only a small proportion of the fat is used for fuel. The high energy content per unit weight of fat provides a vast source of potential energy reserves. In contrast to sugars, fat needs to be oxidized before use. Endurance training improves the ability of fat usage by improving the blood flow and the mitochondrial content in skeletal muscle. In prolonged exercise, free fatty acids (FFA) provide approximately 70% oxidative fuel as compared to glucose. Studies have shown that individuals who train substantially have lower triglycerides and higher HDL levels (MSSE, August 1990). Fats are also used during low intensity aerobic exercise. The sparing of glycogen during endurance activities slows down the use of the same. For prolonged sub maximal exercise, oxidation of fatty acids provides the maximum energy. Respiration also changes, allowing greater use of fatty acids. The muscles themselves may be the source for the free fatty acids. Carbohydrates These can be degraded without the direct use of oxygen. During prolonged exercise (anaerobic), glycogenolysis provides a large amount of fuel for muscle contractions. Skeletal muscle has a high glycolytic capacity. Exercising muscle may increase glucose intake eight to twenty fold and this is met by increased glucose production and mobilization. To prevent hypoglycemia, free fatty acids are mobilized and utilized to the same extent as glucose during moderate exercise. Glucose is provided to the level of 30% in prolonged exertional activity. Several hormones play a role in this. Catecholamines, glucagon, growth hormone and cortisol increase, while the level of insulin decreases. All these ensure hepatic output of glucose and peripheral lipid mobilization during

exercise. These neuro-endocrine changes ensure the maximum amount of energy the muscles need. Muscle biopsies done on professional athletes give evidence of the glycogen-sparing effect. In yoga, one is reasonably conscious of the effects of asanas on body metabolism. We can feel the change during and after asana practice. The major difference between yoga and endurance training is the method of metabolic stimulation. For example, forward bends reduce the metabolic rate of the body and energize the system. It is like recovery from hibernation while back bends stimulate the body and the heat can be felt. Certain asanas warm up select areas of the body while cooling other areas. In the forward bends, the gastric area can get ‘hot’ while the face feels ‘cool’. Hunger pangs are felt. The muscles of the back feel warm. In the back bends, the muscles on the front of the body feel the heat. The face feels the warmth. Thus, regional control of metabolism is possible in yoga. Depending on the geometric shape of the asana, the body can either have a uniform metabolic change or different changes at different points simultaneously. This affects carbohydrate, fat and protein metabolism in all areas, maintaining optimum functioning. The skin blood flow The initial response to short duration exercise is a vasoconstriction of the blood vessels in the skin. If the intensity and duration of the exercise is increased, it becomes necessary for the body to dissipate the excess heat developed. The blood flow to the skin increases and the vessels dilate. Both these functions are controlled by the sympathetic nervous system. In severe training, the blood flow is also preferentially shunted and maintained in the vital organs, and a dual state of circulatory adjustment exists. Depending on the type of sport and the parts of the body used, the temperature of the skin rises in some areas and decreases in others. In contrast, during yogic practice, the reflex vasodilatation of the vessels is made voluntary (to an extent). The practitioner has time to adjust the geometric shape of the asana to suit the need. Moreover, during asana practice, the type of stimulus used to enhance the blood flow is softer and slower, the metabolic rate of the body not being disturbed as in athletic training. The quality of blood flow as well as the effect on the skin due to habitual practice of asanas is quite different from that due to sports activities. The skin of a sportsperson is hard and gritty, while that of the yogic practitioner is soft, supple and glossy. Alignment is also given to the skin, stretching or contracting it in a very precise manner. In sports, the nature of stimulus to nerves that control blood flow is of high intensity and in spurts, while in asana practice the stimulus is slow and steady, so that the skin is not ‘beaten’. In sports training, the skin receives blood flow with a pulsatile quality due to the increased heart rate (with an effect similar to that of leather tanning). In asana practice, the flow is slow, gentle and of a wafting quality, more conducive to cellular health in the long run. If needed, even a dynamic quality of blood flow can be imparted, especially in the practice of back bends. The generation of heat during endurance training is swift and forcible, while in yoga it is steady and controlled. In general, the standing poses create a warm feeling in the legs due to increase in blood flow. Head and Shoulder stand invigorate and cool the tissues of the face. It is to be remembered that, in all these poses, the blood flow to other areas is also altered if needed, depending on the type of

pose.

The musculoskeletal system Bones For a long time, it has been known that exercise is a potent stimulator of bone formation and somehow influences remodeling. In recent years, many new facets have been discovered by researchers in the field. The fact that extensive immobilization decreases bone mass is well known. The determinants of bone structure are a healthy diet with calcium, exposure to sunlight, physical activity and the influence of the reproductive and endocrine systems. Athletes generally have a bone mass greater than nonathletes. Compared to sedentary individuals, runners are shown to have a higher bone density in their femurs. Hudson and colleagues (Journal of the American Medical Association (JAMA), 244: 11071109, 1980) found that tennis players have a greater bone mass in the dominant hand than in the unused hand. Studies have shown that swimmers have lower bone density than athletes involved in land sports such as basketball. In a yogic practitioner, the general appearance of the skeleton is the same after many years of practice, while in the athlete it appears thicker and bulky. If the athlete deconditions, the wastage is pronounced, and the difference is felt more than when a yogic practitioner stops practicing. Muscular pulls on the skeleton have been shown to stimulate bone deposition. Orwoll found that habitual swimmers had a higher bone density on the vertebral column (Archives of Internal Medicine, 149: 2197-2200, 1989). In yoga, forward bends, twisting poses and back bends provide stimulus to the vertebral column. While a person with unhealthy bones, (as in Paget’s disease), might suffer if dynamic exercises are practised, yoga is safe as the stresses laid are of a different quality. Habitual activity slows down age related bone loss. Ayalon et al (Archives of Physical Medicine Rehabilatation, 68: 280-283, 1987) found that postmenopausal women on a training program, with loads on the wrist and forearm, developed an increase in bone density. It is not surprising that the effects of muscle training have an impact on the bone. In fact, as the bone and muscle are in close contact, it is inevitable that the movement of the muscles affects the bones, like water flowing on rocks affects the surface of the stone. Sinaki and Offord have found a positive correlation between bone density and the health of the muscles in that area. Though all these are recent studies, yogic preceptors had an intuitive understanding of the human body and had stated ages ago that the skeleton becomes stronger by regular exercise. In asana practice, the muscles actually massage the bones and do not pound the surface. This maintains the health of the bones even without the need for aerobic exercise. Whatever anatomical bony model is provided by nature, yoga maintains the health of this to a ripe old age. In athletic training, due to the tremendous increases in the stresses laid on the bone, the various anatomical impressions are deeper and more pronounced. No doubt the bones are strong, but yogic training also maintains this strength without the need to pound the bones. For example, the use of standing poses makes the lower limbs so strong that, often, even athletes find it difficult to perform the poses, though their bones are sturdier. The use of balancing poses places loads on the body different from isometric exercises. The variation in the load

is so much that every part of the body is subjected to constant stress, stimulating the bones to remain healthy throughout life. In balancing poses, the stress on all parts of the body is simultaneous, unlike in sporting events where the load distribution depends on the type of sport. Another matter of significance is the increased incidence of fractures in the body following physical exercise. Stress fractures occur when the bone under stress cracks without overt strain applied to it. This is a result of habitual stress on the same point, usually in the wrong manner. This is more common in individuals who begin training after middle age and are not given proper guidance about their program. Fractures have been associated with all kinds of sporting events — tennis, rowing, baseball, throwing events, running and swimming. Habitual walkers suffer from stress fractures of the third metatarsal. Stress fractures of the lower extremities are the most common and comprise approximately 95% of the whole. The femoral neck constitutes around 10% of the lower limb fractures. Bone scintigraphy is a very sensitive test to detect early stress fractures and is usually positive 24 hours after the fracture. Any bone in the body can be involved, depending upon the nature of the stress and the type of sport. Athletes must be very careful not to over train. Muscles When a muscle is stretched, the physiological response is reflex contraction, similar to that of an elastic band. This is an inbuilt reflex to prevent a tear. When the stimulus is jerky, the end result is that the muscle contracts and remains shorter than it was at first. Also, the jerky movement irritates the tissues and the muscle is never soft and supple. Sporting events make the muscle hard and unyielding. The athlete suffers frequent tears, strains and aches of the muscular system. The nature of stimulus to the muscles is a dynamic, repetitive, jerky stretch. This ultimately makes the muscles stiff and the athlete is forced to ‘warm up’ every day. Even though the athlete is in peak form, frequent muscle, tendon and ligament disorders occur. An experienced practitioner of yoga never needs to warm up for many advanced poses, as the body is ever responsive due to the controlled, conscious, integrated type of stretching (and contraction) applied. None of the adaptive changes that occur in the body of the athlete occur in the practitioner of yoga, as the nature of stimulus is different. (See illustrations of Uttanasana, page 95, and Hasta Padangusthasana, page 99.) A healthy muscle should have a balance between softness and hardness, between rigidity and flexibility. Excessive flexibility is as harmful as rigidity. Muscles subjected to repetitive movements become hard and nodular over the years. This is in contrast to the body of a yogic practitioner, where the tissues are soft and supple; yet a healthy hardness is maintained. The athlete’s muscle has a higher resting tone, while that of the yogic person is at the optimum. The athlete is never as flexible as the yogi as the training is different. It is essential to have a great deal of flexibility (which does not necessarily mean only stretching) if the sportsperson is to perform for an extended period of time without occupational hazards. In sports training, isometric and isotonic stresses are given, and the importance of flexibility

programs is recognized to a greater extent today. As a sportsperson needs endurance, speed and stamina, the muscles necessarily harden. If it is only a question of health maintenance, the athletic way of conditioning is not needed for improved and healthy muscular efficiency. Yet I would not encourage anyone to give up this method of stamina building as it is good to retain it throughout life. It is essential to ensure that the muscular system can function to a ripe old age as it functioned in childhood. This is ensured by the practice of yoga where the blood supply is maintained, flexibility and rigidity ensured, and load bearing capacity helped by the balancing poses. The moment the athlete starts practicing yoga, the difference is realized. Many professional sportspersons all over the world are practicing yoga and are realizing the benefits in terms of fewer injuries and less fatigue to their systems. During athletic training, muscles exhaust their glycogen store and the build up of lactic acid is excessive. The type of demand made on the muscles is one of alternating stimulation and fatigue, repetitively, and this, in the long run, produces obvious signs of wear and tear in the system. The number of mitochondria alters, and the muscles learn to function for a longer duration even anaerobically. In muscles trained athletically, or with body building gadgets, the arteries and veins are compressed by the same muscles that are developed. For a yogic practitioner, the state of blood flow is easier due to no ‘knotty’ obstructions in the muscles. There are two types of muscle fibers that are used, depending upon the kind of body activity. Activities needing speed recruit fast moving but easily fatigable muscles, and those needing strength, but not speed, employs slow moving fibers. The muscles of the sprinter have increased levels of glycogen, adenosine triphosphate (ATP) (which is the basic energy molecule of a cell), phosphorylase phosphofructokinase, and increased activity of metabolic reactions that ensure fast and adequate supply of glucose to the working muscle. Athletes train their bodies depending upon the nature of the sport. Strength training causes hypertrophy and hyperplasia of the muscles. As an ongoing process, biopsies from muscles of professional body builders have shown evidence of muscle regeneration and degeneration. It is also thought that more connective tissue is deposited around the muscles, which adds to the bulk. Such changes do not occur in the body of the yogic practitioner, as the nature of stimulus is different. Most definitely, the adaptive enzymatic changes found in athletic muscles do not occur, as the manner of exercising is different. There is no need for the body to adapt, since blood flow to all parts of the body is maintained, cellular health is ensured, and all the tissues in the body are kept healthy without any change in parameters like blood pressure and oxygen usage. Another important factor in endurance training is that of fatigue operating as a limiting step. There are several mechanisms by which fatigue occurs. Some of the causes include accumulation of lactic acid, hydrogen ions, phosphate, ammonium ions, and loss of the cellular energy molecules. In any case, fatigue does occur, and this is nature’s built-in reflex to protect the system. The other important factor is the role of the mind in fatigue. In spite of physiological exhaustion, the power of the mind in influencing the body to achieve is something that modern medicine recognizes but cannot explain. Yogic science has always been insisting that the mind is the centre of all power and, if all the reserves of the energy centers in the mind are tapped, fantastic results can be achieved. This explains

the yogic powers which, according to the practitioner, are along the lines of the laws of nature. In yogic practice, the kind of fatigue is of a very low grade and the body is ‘flogged’ in an entirely different manner. In yoga, the accumulation of lactic acid and other metabolites is minimal and does not affect the performance of the joints and muscles. A common problem in athletes is that of repetitive tears of tendons, ligaments and muscles. This is due to the repeated stress of a dynamic nature on the tissues. Fatigue occurs due to constant high intensity and high impact movement, and the ligament or muscle easily tears. Tendons require greater force than muscles to be torn; the fact that this happens is enough proof that strong forces are generated during sporting events. The crux of the matter is that, in sporting events, the body is used like a race horse which has to tire some day, to become a cart horse. Wear and tear occurs if proper servicing is not done. Evidence of muscle damage has been found in the body of athletes through biopsies which reveal clear elevation of muscle enzymes. When these persons are subjected to high intensity activity, no further increase in the enzyme levels occurs, showing that some sort of adaptation has occurred after extended practice. This is not surprising as the body in sports is subjected to high stress and the system, while producing fantastic results, suffers internally at the same time. Sportspersons should protect their bodies by practicing yoga which soothes the muscles and prevents tears and sprains. As the movements in sporting events are fast, there is no time for reflection and readjustment to provide for alignment and correct tensions on the joints and muscles. Extension of muscles, bones and joints occurs with tremendous tension in sporting events. However, in yoga, extension occurs without tension due to differences in the manner of training and the logistics of the science. The geometric shapes of the asanas are very many, thus providing a variety of stimuli to the muscle. During yogic practice, a lot of emphasis is placed on alignment and centering, and the movements cannot be classified as isometric or isotonic. A contracting muscle can be stretched without losing its state of contraction. This is the uniqueness of yogic movement. In sporting activities the cells are in a state of exhaustion, while even at the end of yogic practice energisation occurs with a given substrate of energy. Joints A healthy muscle makes for a healthy joint. Movement of the muscle tones the joint and improves blood circulation and free flow of nervous energy. In endurance training, the joints are frequently sprained, due to the high intensity of impact and asymmetrical usage. The strain may be mild, moderate, or severe, depending on the type of event; and may vary with individuals, depending on factors like their height and thickness of limbs. The joints are pounded, making the ligaments and joint capsules stiff and non-resilient, and prone to tears and sprains. Though proper techniques are followed, the nature of the activity is such that injuries result. Hence, it is essential that practice of yoga be resorted to. Sprained tissues need rest and a short course of analgesics and hot (or cold) packs help. Eventually, rehabilitation through yoga is necessary as it is the best method to handle joint injuries. Asanas

massage the joints and strengthen them along anatomical planes. The joints remain elastic. The shockabsorbing capacity of a joint trained through yoga is far better than with any other system. Flexibility and strength are provided simultaneously. The vast variety in geometric shapes allows different kinds of stresses to be placed on the joints, thus building up maximum health. All categories of asanas are useful, particularly the standing poses. Padmasana and Virasana are valuable for athletes who use their feet often. Hand stand and Elbow stand are useful, along with back bends and inversions, for the athlete using the upper limbs. In yoga, the joints are moved through seemingly unusual positions; but there is a rational to each position and in no posture are the anatomical tenets broken.

The sportswoman and her problems Nowadays, sports training of both men and women are equally intense. The female athlete has special problems due to her differing physiology. The trainee has a smaller heart size and heart volume, and higher heart rate, hemoglobin concentration and oxygen content of the blood. Women, in general, have smaller-sized hearts, especially the left ventricle (Riley Hagan, American Journal of Cardiology, 1974). With regard to the ejection fraction no difference has been found between men and women under exercise training. Systolic blood pressure rises a week prior to the menstrual cycle and starts reducing by day three. Women secrete more catecholamines during exercise, while men do so during non-exercise stress. A female also has a smaller lung capacity than a male. There is a sex difference in regulation of skin blood flow which is abolished after menopause. The general isometric strength is greater in men than in women. The higher muscle mass in men is probably due to the circulating androgen levels. Due to fat deposits, women may have a greater insulative quality when exercising in the cold. This is offset by a decreased capacity to generate metabolic heat and hence more cooling of the body may occur. Both men and women are similar in their reactions to exercise at high altitudes. The response of circulating lipoproteins to exercise appears to be greater in post-menopausal than pre-menopausal women; and this suggests that estrogen in the pre-menopausal years is somehow cardio-protective. The reproductive system of women Endurance training affects the reproductive system (Marcus et al, Ann.of Int.Med., 102: 153-158, 1985). Numerous studies have established that menarche occurs later in athletes than in non-athletes (MSSE, June 1992). Athletic training could impair the mineralization of pubertal bone due to the high stress on the tissue or delay in the onset of the menstrual cycle. Studies by Bullen and associates (New. Engl.J.Med., 312: 1349-1353, 1985) indicate that the amenorrhea in female athletes is linked to the effects of training. The pituitary hypothalamic axis is affected by training and this in turn affects ovulatory mechanisms. The second factor that upsets the reproductive system is that of improper nutrition. All this represents only the tip of the iceberg. Many more studies will reveal a wealth of information. The female athlete triad includes poor nutrition, consequent amenorrhea and osteoporosis. A pragmatic view is essential to prevent all these disorders from taking root. In recent years, more women have taken to body building. This is certainly injurious to their

physiology. While the female contour is lost, it is also highly likely that the biological functions will be affected. While one part of the body may benefit by a particular activity, other parts will be adversely affected. As the body of a woman is biologically different, certain guidelines must be followed if health is not to be endangered by sporting events.

Various sports and their innate side effects The injuries vary according to the kind of sport played and how careful the sportsperson is. Unless early action is taken, the side effects can be disabling. The inner organs are also affected by sporting events. This does not mean that one has to avoid sports, but that one should be aware of the inherent problems. The practice of yoga is of great value to a sportsperson as it not only helps to prevent the side effects, but also sets them right and maintains the physique. I have discussed different sporting events in the following pages, pointing out the stresses laid by each type on the body. I have also shown how yoga can help to combat these. Regarding treatment of injuries, the use of plaster casts, crepe bandages, analgesics and rest given to avoid strain are useful according to the condition. When the affected part is healed, asana practice should be instituted as early as possible. If analgesics and rest have not improved the situation, yoga practice must be begun after careful consideration of clinical parameters. Running I have chosen to discuss running first and in some detail, as this is a popular form of exercise, and one where injuries can occur easily. The incidence of injuries depends on whether the runner is a professional or an amateur. In both cases, however, injuries are on the rise. What are the risk factors for injury? Adequate importance is not given to flexibility programs. Some individuals suffer from anatomical imbalances like flat feet, short legs, excessively lengthy spine, bow legs, and knock knees, all of which have to be taken into account when flexibility programs are introduced. Changes in training schedules, with too much addition all at once, and cross country running are some of the other factors. Where does the injury occur? The foot and the ankle The lower extremities and the spine account for 50% of injuries. The foot suffers from repetitive high strain and, in the long run, it suffers from muscular imbalance, losing its arch. The fat pad on the heel wears out and plantar fascitis (inflammation of the tissues of the sole) occur. Calceneal spurs can also occur. Stress fractures are very common which can be asymptomatic or accompanied by constant pain unrelieved by training. Women athletes have to be screened carefully as they are particularly prone to demineralization of the bones as already discussed. Constant impact wears the ankle. Recurrent sprains are common and the injury lasts a while. Poor footwear and ill-fitting shoes are other factors

that can cause injuries. Achilles tendonitis is frequent. Athletes cannot stretch the tendons optimally while practicing asanas. In fact, many parts of the body struggle when asanas are performed as the body is stiff and resistant. The knee The knee accounts for 30% to 40% of injuries. As running is a high impact movement, the wear and tear rate is accelerated. The constant pounding action thins down the cartilage, leading to premature degeneration of the joint. More than tears of the cartilage, the extensor mechanism of the knee is frequently sprained. The quadriceps muscle suffers recurrent sprains. The patellar tendon becomes inflamed as it absorbs the constant impact of the pounding force. Athletes with genu varum (bow legs) or genu valgum (knock knees) are more affected than others, as the weight transmission is not in the perpendicular path. The inner surface of the patella (and the anterior surface of the femur on which it rests) is prone to friction and inflammation causing premature wear and tear of the structures. The lower back, the hip joint and the cervical spine These account for 10% to 20% of injuries. Stiff necks and lower backs are very common in runners. The hip joint is also affected to some extent as the inner groin muscles are frequently sprained. Imbalance in training leads to unequal development of the hip joint muscles and the overdeveloped side suffers pain. Even with proper training, the more frequent site of pain is the lower back. This is not surprising, as the lumbar spine is the recipient of compressive stresses that are transmitted by the heavy pounding action. In order to absorb the impact, the muscles contract at the moment of impact and, with constant use, remain tight all the time. This leads to chronic stiffness and pain, and a sudden movement tears the fascia and the disc. These injuries are tolerated by the sportsperson as the mind is conditioned to bear a high degree of pain. It has been shown that around 9% to 12% of long distance runners suffer from low back pain. It has been demonstrated that these compressive forces can affect the disc and thus affect spinal height (MSSE, Dec 1990). Loss of fluid from the disc has been shown to be the cause of spinal shrinkage. The speed of the run is the main factor that affects the spine. As the disc stiffens, it becomes more prone to injury. There is a tendency in the sportsperson to push the body to a high level of training without recognizing the danger signals. Though all these problems are commonly found with running, there is an important, often forgotten factor. This is the chemical adaptive change in the muscles of the marathon runner (MSSE, May 1992). This is not a desirable influence for the body. The inner organs The benefits of running are at the cost of the inner organs. The heart and lungs are ‘irritated’ by the sport. This does not mean that the runner is not healthy or fit, but the stimulus is ‘noisy’ and does not provide the cellular tranquility that yoga does. In this sense, all exercises except yoga are termed irritative. With yoga the nature of irritation is different. Cardiovascular fitness is built up by running, but this is at the cost of adaptive changes in the heart, muscles and diaphragm. In women, the

reproductive system is affected, resulting in amenorrhea in some cases. The abdominal organs are disturbed by the constant movement which causes cramping of the circulatory flow. Yoga and the runner The endurance capacity of athletes cannot be retained for long periods on account of aging. If running is for the sake of health, it can be shown to be not necessary at all. If the sport is a personal preference, it is a different matter. There are other methods, like yoga, which not only maintains health but helps to repair the injuries incurred in the sport. There is a misconception that health is achieved only by aerobic exercises. Millions of joggers push their systems every day, not realizing that enhancement in circulation can be achieved without strain by just a single asana. Yoga is a nonirritative method of stimulation. For example, the back bending asanas in the yogic system stimulates the entire system without irritating it. Running reflects the human potential to achieve. The athlete need not discontinue the sport, but should take precautions to prevent injuries. The flexibility programs offered to runners do not inculcate the principles of alignment. Practice of yoga with alignment protects the athlete from injuries. The principal components of yoga improve the shock-absorbing capacity of the system, soften the unhealthy areas and harden the areas where such stimuli are needed. It is ideally suited for the runner. The nervous system is soothed in yoga. This strength is essential for the runner whose system is constantly in a state of noise, like a steam engine. The training routines are incorrect. Intervals of rest followed by training are not the correct method. The rest given by yoga allowing better performance is the way. Rest need not mean cessation of activity. Passive exercise is also a form of rest. The legs are the basis for a healthy run. All standing poses are invaluable. The directions of movements are so varied that every part of the muscle, bone, ligament and tendon can be worked. Though the runner’s legs are very strong, they are not as stretched as in yoga. Their muscles become more resilient after yogic training and they can run without repeated sprains and tears. A yoga practitioner may not be able to run like an athlete and an athlete finds it difficult to practice asanas. Yet, as the athlete needs to run, yoga can be used and a balance can be brought about between the toughness of the tissues caused by running and the resilience of yoga. The cartilages which are constantly pounded by the impact of the run are strengthened and massaged. The hamstring muscles which are tough and hard due to hours of running are softened by the stretches. Likely tears are prevented. Problems of anatomical disproportion are countered by asanas. The arches are strengthened and chances of stress fractures are reduced, as the bones are subjected to a different type of stress which protects them. The Achilles tendon is made elastic and tears seldom occur if yoga is practiced. Dog pose is particularly valuable as it stretches the Achilles tendon. Asanas such as Trikonasana, with the heel pushed into the wall, Hanumanasana, and seated forward bends with the foot dorsi-flexed, are invaluable for this purpose. Cramps in the calf muscles are also relieved by these asanas. Bending in Uttanasana with the foot on the semicircular brick, and standing poses done with the heel pushed into the wall (see illustrations of Trikonasana, page 95 and Virabhadrasana, page 96) are invaluable for the calf muscles. The

tibia is prone for stress build up to the extent that many runners suffer from sore muscles in the shin area. Practice of Virasana relieves and prevents this pain. Runners, walkers and joggers can suffer from the “anterior compartment syndrome”. The muscle lateral to the shine bone is called the tibialis anterior and is surrounded by a sheath. This is the anterior compartment of the leg. Exercising muscles need space to function and tend to bulge and if the fascia is not elastic, the bulge causes pain and swelling, and limits further movement. Usually this problem occurs due to over usage. Symptoms include pain which increases during exercise which eventually makes walking or running impossible. Pain subsides after a short rest but resumes during exercise. Surgery is not needed for such over usage induced problems as yoga has several asanas which can stretch the fascia itself to provide permanent relief and cure. Other causes of this syndrome include injuries which may need surgical decompression. Virasana, Padmasana and Dog pose prevent and cure this condition. Habitual practice of these asanas prevent compartment syndrome. Virasana cycle protects the shock-absorbing capacity of the knees and ankles. In the knee, the opposing surfaces of the femur and the tibia are separated and the cartilages are relieved from the stress of the pounding action. Padmasana gives great relief from the trauma of the run and one can actually feel the relaxation as it is being practiced. Both Padmasana and Virasana squeeze different parts of the knee joints with a massaging action. This action specifically relieves the impact of pounding stresses. The patello-femoral articulation is prone to developing inflammation, and this is greatly prevented by Virasana and Padmasana. Even after inflammation has developed, the asanas relieve pain. If there is a tear in the cartilage, surgery is not mandatory in all cases. In the majority of cases, conservative management with yogic exercises is adequate to bring the athlete back to normalcy. The injury eventually heals with fibrosis, and any instability or loss of strength can be prevented by the regular practice of asanas. After sufficient yoga practice, weight training will help the athlete to function well. In a few cases of very severe tear of the menisci and the anterior or posterior cruciate ligament, surgical repair is needed. The quadriceps muscle, which so often suffers cramps and strains, is kept healthy by asanas like Hanumanasana, Virasana and its variations. The hip joint and the groin move in a well coordinated manner. Any tear of the groin muscle, which is common in athletes, renders effective usage of the hip difficult. All standing poses, asanas like Supta Padangusthasana with the leg laterally stretched, Upavishta Konasana and Baddha Konasana, are invaluable for the athlete. A common mistake that the majority of sportspersons do is to overstretch the inner groin muscles in Baddha Konasana, resulting in sprains that do not heal well. Even if they achieve flexibility, it is with a certain quality of rigidity at the same time. As the movement of bending forward starts from the inner groin muscles, forward bends provide excellent flexibility. The lumbar region is the most important area to be attended to. A majority of athletes suffer from low back pain at some time or the other. This is due to lack of healthy flexion of the spine. In athletes, the muscles are stiff. Proper practice of basic back bends like Urdhva Dhanurasana and Viparita Dandasana results in a very strong bony column, resistant to wear and tear. All the other asanas are also useful. The sportsperson finds it difficult to make the back concave in the standing concave poses. Once this is achieved, the back is healthier.

The dorsal spine develops a hunch due to the constant stoop assumed in training and also for the start up posture for a run. The muscles become hard and inelastic. Proper practice of back bends, especially on the ropes, helps correct the situation. Forward bends done on the wall with the body hanging on the ropes, as in either hanging Uttanasana or hanging Paschimottanasana, help to loosen the muscles in a very short period. The practice of standing poses with the horse prop, to learn the intricacies of alignment and achieve better stability in the body, is important for the athlete. The cervical spine, though placed distant from the lumbar spine, nevertheless suffers from the impact of running. The trapezii and the muscles of the shoulder and arm are tightened in the effort made to improve running. This prevents proper shock absorption and the muscles become hard. Sprains and aches are the most common complaints. Correction of the running technique and practice of inverted asanas like Head stand and Shoulder stand give the necessary strength and suppleness to the neck and trapezius areas. The heart and lungs are rested periodically by Supta Virasana. Uttanasana done with the arms folded, between events, provides quick recuperation (see illustration, page 95). Practice of pranayama develops stamina. Kumbhakas (both internal and external) are useful to develop energy. In the state of retention, the energy drawn in is retained and is properly stored and circulated. If the lungs are exhausted, pranayama in the supine position with pillows refreshes the athlete. Excess ‘heat’ in the body is removed by Sitali pranayama. This is valuable for the marathon runner. The heart and lungs are protected by back bends and forward bends. The latter remove stress and strain on the heart and lungs, and prevent cardiac hypertrophy. The abdominal organs are also toned by asanas like Supta Virasana, Purvottanasana, twistings and back bends. Women athletes, who are prone to suffer from amenorrhea due to high intensity practice, will benefit from inversions and back bends. Their reproductive systems will be better protected if asanas are practiced regularly. In a nutshell, the runner should prime the body with the practice of yoga even before learning the basics of running. The entire body of the runner will be molded by the practice of asanas every day.

The jumps — high, long, triple and the pole vault The movements in the various jumps are always done in a manner that uses one leg excessively. The high jumper, for example, uses only one leg to jump off the ground, and the body is tilted to one side in the process. The repeated use of the same side of the body results in asymmetry, and aches and pains occur. The groin muscles are opened only on one side and the hip joints are also subjected to a one-sided strain. In the case of the long jumper, the launch is with the same leg day after day, and that leg is the stronger of the two. Similar is the condition with the hip joint and the paraspinal muscles. The hamstrings of one leg are used excessively, while the other leg is passive. In the triple jump, the person uses one leg to hop and step, and the last part — the jump — is more strenuous than the long jump, the strain always being on the other leg. The practice of using both sides of the body should be inculcated in athletes as soon as training is started. This may sound impractical but is not impossible. Unless ambidexterity is achieved, the body suffers. Bilateral training is a matter of practice and can be achieved. Standing poses help achieve equilibrium in ambidextrous faculties. Right or left handedness in children is only a matter of conditioning and not due to dominant hemispheres. In childhood, any hand can be trained to dominate.

However, in the athlete, fixity occurs over long years of training and this harms the body. For the jumper, asanas which open up the groin like Upavishta Konasana and Baddha Konasana, Samakonasana and Supta Padangusthasana, are very useful to prevent muscle imbalances. Hanumanasana optimizes muscle usage in the triple and the long jumper. The pole vaulter stresses the muscles of one hand, usually the left, to vault over the bar. The deltoids and the triceps of the left hand are overused. The body is also twisted only to one side to achieve the final jump. The only way to counter these unequal stresses is to train the body on both sides. While this may seem impractical for sport, it is very necessary for health. Balancing asanas are useful for the vaulter to train both sides of the body for load bearing. In particular, one-sided balances like Vasishtasana and Kasyapasana train the sides of the body and the latissimus dorsi muscles (see Iyengar, BKS, Light on Yoga, George Allen & Unwin, London, 1974). Asanas which are done dynamically with jumps, with coordinated breathing are useful to the jumper. Pranayama relieves fatigue, makes the body light, and releases tension at the time of the jump.

The throws — discus, javelin, shot-put and hammer All throwing events use only one arm. In that arm, only a few muscles are used all the time and, in the long run, the imbalance between the overused and underused muscles gives trouble. In throwing the discus, for example, the palm of one hand is constantly folded, and the other palm is not used. The muscles on the palm are always compressed. The arm that throws is used with a violent fling, and this overstretches the outer triceps and the deltoid junction, and the bottom of the inner armpit area along with the chest. In course of time, the muscles become loose. If stretched over the head, the used arm will move better than the unused arm. The trapezius and the latissimus dorsi are also overstretched, making the used shoulder and the side of the neck appear longer and broader. The real discrepancy is seen when such an athlete performs the asanas. The ease with which the used arm stretches in the movements is grossly visible. Movements to stretch the palm and improve blood circulation are essential. The athlete will benefit if training is given to both sides of the body. Standing poses correct imbalance on both sides of the body. Asanas like Adho Mukha Svanasana, Hand stand, Elbow balance, Sarvangasana with its variations in arm positions, Head stand with its variations in hand positions, different kinds of balancing postures, are all useful for the athlete to redress imbalance of usage (see section on asanas). Not to be omitted are the back bends which exercise the shoulder joints in various positions, removing discrepancies of stretches. The javelin thrower’s problems are comparable to the discus thrower. The biceps are more strained in this event, the angle of throw being different. The shoulder joint is violently pulled from the socket along with the scapular muscles. In the discus throw, the scapular muscles suffer from a semicircular strain while, in the javelin, they suffer a linear pattern of strain. The asanas that help the javelin thrower are the same as for the discus event. In addition, the practice of the reverse namaste removes any soreness from the shoulder joint by internally rotating the joint and the associated muscles of the arm and the shoulder.

The shot-put throw gives the maximum strain to the shoulder joint and associated muscles and ligaments. The heavy fling causes overstretching of the ligaments and muscles. The effects often last for years after cessation of the sport. In the hammer throw, as both the hands are more or less involved, the strain on a single hand is less. Yet, the shoulder is dragged forcibly. The constant momentum built up before the throw somewhat keeps the arms ready for the event, unlike in the other two events where the arm is kept stationary and then suddenly pushed forward. This readiness prevents the sudden strain on the shoulder. The most common problem in all these events is that of the spine being rotated always to the right (left always in a left-hander). The excessive strain on the facet joints results in an uneven and premature wear and tear and a scoliotic deformity. Lateral bends and twisting asanas are useful to prevent the strain on the spine and maintain healthy evenness of usage. Pranayama, with emphasis on exhalation, is important as the throw will be easier during the exhalation. Special attention has to be paid to the overused side during pranayama, to prevent greater activity of respiratory movements.

Archery In archery, one eye and shoulder are strained excessively and one side of the brain is used more than the other. The pull of the arm backwards results in a contraction of the biceps, and stretch of the triceps, and contraction of the scapular muscles. In the arm that pulls the string of the bow, the trapezius muscle that connects the root of the neck to the shoulder joint is made to contract repeatedly. Over the years, the sportsperson develops a nodule in the trapezius. On the other side, the scapular muscles are stretched along with the latissimus dorsi and the rest of the hand. There is no difference in the occurrence of problems even with modern archery gadgets, though some mechanization has occurred. The neck muscles are also used in a lopsided manner, like the eyes, as they turn to one side constantly. The extended arm is overused in the act of constant stretching. Standing poses, which use the eyes symmetrically, help the archer to train both sides of the orbital muscles and the focusing of the eye. Hand stand, Elbow stand, Dog pose done both ways with fingers on the wall and in the opposite direction, balancing poses and unilateral balancing poses like Vasishtasana, are useful to achieve balance of both sides of the body including the hands. Forward bends relieve eye strain while back bends provide confidence. The archer must use the inactive part of the body more in asana practice so that it compensates for the disuse during archery. Pranayama of the contemplative type (Nadi Shodana) is highly useful for the archer who is unable to concentrate. In this, the mind has to become quiet, and the sensitivity of the fingertips is honed to trace the passage of the breath. Such training helps the archer and the shooter (see following paragraph) to stabilize the mind and brain to concentrate at the time of the release of the missile.

Shooting The hand positions in shooting are similar to archery, except that the left arm is held bent instead of extended. The weight of the gun is different and the recoil varies with the caliber. The butt of the gun digs into the shoulder and, over the years, creates a pressure pain on the inner deltoid muscle. The position also uses the outer deltoids more than the inner. The inner is always stretched. The trapezius

on the side of the butt is chronically contracted. The hand that holds the gun from the bottom suffers a contraction of the deltoid and the triceps and biceps. The usage of the eye is similar in principle to archery. The asanas that help the archer also help the shooter. For both, the use of the ropes on the shoulder, in the form of a harness, relieves the strain on the trapezius and prevents nodule formation. Dog poses, Hand stand, Head and Shoulder stand with the belt, all relieve elbow and shoulder problems (see illustrations of Sarvangasana with belt, reverse namaste, and use of belt on arms, page 96). In both archery and shooting the eyes are strained to the maximum. Practice of forward bends, with the bandage on the eyes, and of Shanmukhi Mudra, is beneficial to relieve eye strain.

Tennis The serving arm is used excessively by tennis players, producing the speed of the serve. The other arm is grossly underused. The wrist also suffers the same fate. In the well-used wrist, the bones and muscles are firmer and larger. The forearm is thicker on the dominant hand. The rotators of the back are used more towards one side and the vertebrae are twisted always to one side. The excess stress creates spur formation on the vertebrae. If the player has a habit of top spinning the ball, the inner elbow and wrist are overused. If the backhand stroke is single handed, the outer forearm and upper arm muscles are preferentially used. If double handed, the inner forearm and upper arm muscles of the helping arm are overused. However, it is the dominant arm that is always overused. The inner elbow is prone to inflammation if the player does not maintain adequate tension of the forearm muscles at the moment of impact — the so-called ‘tennis elbow’. The spine and neck are always overly twisted to the opposite side. If the playing style is one of overextension of the spine in reaching for the ball during the serve, the resulting momentum and twist is extreme. The rear knee always takes more weight at the beginning of the serve. The foot on the other side suffers excess weight transmission at the end of the serve. The shoulders are protected by movements in head and shoulder stands. The reverse namaste is valuable to prevent excess wear and tear in the head of the shoulder joint. A good policy is to instill the habit of using both sides of the body even as initial training begins as a novice. Asanas like Hand stand, Dog pose including the upward dog, balancing poses, inversions and unilateral balancing poses help relieve any pathology in the shoulder and the elbow (see illustration of Urdhva Mukha Svanasana, page 97). The practice of these asanas also prevents the onset of elbow problems. All standing poses help the player to be more limber on court, prevent misalignment and pain in different parts of the body. Back bends give the endurance needed as it is common to see players gasping at the end of the serve after many games. Forward bends provide rest for the system, both between and after matches. These can be done with the props if fatigue exists. Viparita Karani, followed by Supta Virasana, is valuable to give the entire neuro-endocrine system rest and recuperation after a match. The hamstrings and the Achilles tendon are kept elastic by asanas like Hasta and Supta Padangusthasana. The knees are protected by Virasana and Padmasana. Pranayama helps improve endurance in long matches.

Squash Squash is a typical example of a high impact sport. The limited space available forces quick

acceleration and prevents proper deceleration of body movements. The movement (when the ball is reached for) has to be abruptly terminated to move in another direction. As the ball is bounced from very close quarters, there is very little resting period for the forces of acceleration and deceleration. This results in the knee and the hip and the back absorbing the impact. In the long run, many suffer chronic shoulder pain and knee pain, especially in the region of the medial ligament. The forces that work on the hand and the shoulder are far greater than in tennis, and the violent swing can injure the ligaments of the shoulder. Tears of the ligament are not uncommon. The high impact on the foot results in strained arches, pain in the soles and flat feet. This sport is fast and forceful and the nerves get exhausted quickly. The entire spine is used asymmetrically and with high impact. The shearing forces on the muscles are very forceful. Sprains of the spinal muscles are common. The shoulder ligaments are prone to becoming overstretched. Reverse namaste, salamba Sarvangasana, half Halasana and Baddha Padmasana are useful to retain the tightness of the ligaments. The knee and foot are helped by Virasana which relieve the strain of the impact by its massaging action. It is important to practice resting poses like Setu Banda Sarvangasana and passive forward bends to recover from fatigue. To protect the spine, standing poses are invaluable. The higher incidence of low back pain is due to the high striking force of the heel. The usual routine of asanas for low back pain relieves the condition. This includes Bharadwajasana near the wall, standing Marichyasana, lateral bends like Trikonasana, Parsvakonasana, Dog poses, Pawana Muktasana and Savasana with weights on the lumbar spine to massage the muscles. In spite of adequate precaution, many suffer chronic low back pain and knee disorders. The nature of the game is such. Yoga does protect the body, but the intensity of the knee strike should be reduced if the knee and back are to remain healthy in the long run. In both these sporting activities, endurance and quick recovery from fatigue are needed. All types of pranayama are useful. Bandhas and kumbhakas are necessary to improve endurance. Supine practice is recommended at times of fatigue.

Golf The wrist is most commonly sprained while playing golf. Many play without proper preparation of the wrists and forearms. The dominant shoulder with the associated muscles is over-contracted. The other hand suffers less. The spine is another area of neglect. As the stroke is completed, the entire spine is turned to the extreme left and, over the years, the rotators of the spine suffer the effects of asymmetric usage. Premature degenerative changes occur, resulting in spondylitis. The knees suffer asymmetrical usage and the rear knee is twisted constantly as the stroke is completed. There is pain in the region of the medial ligament of the knee. The eyes also are asymmetrically used. To protect the wrist, practice of the reverse namaste is a simple measure. Asanas involving the wrist, like the Dog pose, Chaturanga Dandasana, Sarvangasana, Halasana and balancing poses, are all useful. The spine and eye muscles can be balanced by all standing poses and twisting asanas near the

wall. All other spinal movements can also be practiced for complete suppleness. As the golfer has to walk for long hours, Virasana with a pillow between the thigh and calf relieves fatigue and pain in the lower limbs. This may be preceded by Viparita Karani against the wall. These can be done either before or after the game. Exposure to the sun for long hours produces heat in the body. Forward bends done passively are valuable to cool the system. Sitali pranayama done before the game is helpful to keep the body cool. At the end of a long game, after resting and cooling off, Ujayyi pranayama done supine is helpful. The constant twist of the body can affect the functions of the inner organs as the nature of the stimulus is one-sided. For example, when the body is twisted to the left, the liver is compressed at the end of the stroke and the spleen constantly stretched. This kind of stimulus should be alternated. Similar effects occur on the lungs, kidneys and diaphragm. All asanas, particularly rotations, side bends and back bends, are valuable for this.

Cricket This is one of the world’s more popular games, where players have to use headgear and other protective devices to shield themselves from injury. Awareness of the need for pre-match conditioning is greater than before. Yet, the body suffers from several problems. The batsman The right-handed batsman has to constantly bend the body forward and incline the spine and the eyes to the left. The left hip always projects along with the left shoulder. The right shoulder is always lower than the left and the clavicular area is hollowed out on the left. Both the trapezii are contracted. The inner knee is prone to more weight bearing along with the inner ankle. The shoulder will benefit by backward extensions on the bar and Shoulder stand and its variations, along with back bends and Hand stand. Asanas work on the knees, turn the spine to the right, push the hip to the right, open the right shoulder and flatten the clavicular area. Forward bends cool the body which is exposed to the sun for long hours. Long hours of standing will be relieved by performing Viparita Karani on the wall, followed by Supta Virasana with pillows under the thighs. Back bends give the batsman the energy needed to play for many hours without tiring easily. Use of props at the end of a long day refreshes the player for the next day. To prevent asymmetric usage of the hip joints, the batsman should practice playing on the unused side quite often. The bowler The bowler suffers from hand, spinal, knee and ankle problems and exhaustion from constant running. The entire spine is always turned to one side, with or without force. The trapezius of the nondominant shoulder is constantly contracted and this forms a nodule in the long run. The cervical muscles are turned to the same side all day, and rotational asymmetry occurs. The knee and ankle on

the non-used side can take excess weight at the time of completing the movement. Before this phase the bowler has to lean back on the other knee and the inner ligament can suffer strain. This is repeated for years. Excessive wear and tear of the spine occurs and can cause degenerative changes. All standing poses, with emphasis on using the non-dominant side, are helpful for the spine, knee and ankle. Trapezius traction (see illustration, page 97) relieves the pain in the shoulder and the nodule can be shrunk. Rotational movements such as standing Marichyasana and Bharadwajasana give relief to the neck. Extension of the neck on the rope, holding the bar behind the back (see illustrations, pp 97, 98, 100), and back bends with rope give relief to the neck and the shoulder. Hand stand and Elbow stand are useful to provide extension for the hands. Inversions, forward and back bends are needed. Back bends give the necessary endurance to the pace bowler. As the bowler has to move constantly, resting poses like Viparita Karani, forward bends on the pillows, Virasana and its cycle are very helpful particularly for the knees and ankles. Half Halasana is valuable for recuperation at the end of the day. The wicket keeper The wicket keeper has to squat and rise several hundred times daily. This can lead to fatigue of the spinal and groin muscles, and produce low back and cervical aches due to constant flexion and extension of the neck with over usage. The hips and the knee joints also face similar strain. The groin muscles are semi-open, retarding healthy blood flow in those areas. The organs of perception are also overused as the keeper has to study the movement of the ball and be very alert. The wicket keeper has to practice various asanas to prevent the back from premature degeneration. Lateral standing poses and rotations relieve the strain on the back. Back bends give enormous relief to the anterior and posterior spinal muscles. Inversions give respite from the constant congestion in the legs due to squatting, which prevents healthy venous return and fresh arterial flow. They also help the neck by flexing it, particularly half Halasana and shoulder stand. Hamstring stretches as in the standing poses and Supta Padangusthasana, Samakonasana and Hanumanasana are relieving to the muscles which are constantly flexed. Baddha and Upavishta Konasana assuage the strain on the groin along with Supta Baddha Konasana. Forward bends and half Halasana soothe the senses. Practice of Shanmukhi Mudra is useful to lighten strain on the mind and the eyes. Use of the bandage on the eyes is valuable. The fielder Fielders do not suffer so much from postural problems. The close quarter fielders flex their spine, hips and knees constantly. The practice of asanas is as for the wicket keeper. Exposure to the sun and loss of fluid and salt deplete energy. Passive inversions and Supta Virasana greatly relieve fatigue. All cricket players need endurance and strength. All pranayamic techniques are useful. To prevent heat exhaustion, Sitali pranayama is beneficial. The bowler’s inner organs face the same kind of stimulus as the golfer’s. The wicket keeper’s posture leads to problems with the bladder and prostate being constantly pressed upon. In the female, the uterus and ovaries are pressed. The abdominal

organs are pressurized in both sexes. To neutralize this, specific asanas should be practiced in addition to other general asanas. Back bending postures are most useful. To get instant relief, pillows or the Viparita Dandasana rack can be used, whenever possible, for the reclining posture is beneficial. In short, the practice of yoga makes for a healthy and better cricketer.

Hockey In hockey, the spine, the shoulders and the knees are the most strained. The player has to bend to one side all the time during tackling. The spine is always inclined to the side; one arm extended, the other contracted. The dominant shoulder is overstretched; the inner biceps and forearm muscles are taxed. The legs are also used asymmetrically with more stress on the rear knee. The spine is laterally flexed to the right and rotated to the left. Flexion of the spine is a constant accompaniment with the need to run about continuously. In the long run, problems of low back ache, wear and tear of the knees and the cervical muscles occur. The mind and senses, forced to follow the ball, suffer exhaustion. Standing poses are done to correct the tilt and rotation. Dog pose is ideal to correct the imbalances in the spinal muscles. The knees also become stronger in the process. Virasana and Padmasana are useful to rest the overused knees. Inversions help overcome exhaustion and, when combined with Supta Virasana, relieve fatigue of the leg muscles at the end of the day. Virasana with a pillow between the knees also gives quick relief to tired legs. Back bends like Urdhva Dhanurasana and Viparita Dandasana are helpful to induce symmetry of posture and movement in the hands and shoulders. Forward bends and supine pranayama with bandage relieve strain on the mind and eyes.

Football An apparently simple game where a ball is just kicked about, football’s effects on the knee are far from simple. Tears in the semilunar cartilage are more common in this than in any other sport. The knee is rotated outward, with the additional strain of weight bearing. In addition to this a sudden jerky movement and the torsional forces tear the meniscus. The tear can heal by fibrosis. If the tear is large, the knee is prone to sudden locking-the most common complaint. The player tries to stretch the flexed leg and the movement is halted midway, suddenly and painfully, due to the torn part of the cartilage getting jammed between the femur and the tibia (as they glide over each other to complete the stretch of the knee). The cartilage can also tear through its full length. Isolated parts of the tear form what are called pedunculated tags. The typical history is of an acute twisting strain, followed by a sudden feeling of something tearing in the joint and the leg buckles. Knee effusion occurs and the patient has to rest for a few days. Once the swelling subsides, activity can be resumed but the problem can recur again suddenly, without warning, with buckling of the knee. Unless the tear is major, it is always good to avoid surgery. Conservative management with rehabilitative exercises is adequate. Yogic exercises are ideally suited. The range of movement in yoga is more, and the nature of load bearing is different. Relief of pain occurs within a few days of therapy. The synovial thickening may take longer to thin down. Resistive exercises used in physiotherapy are not very helpful in the long run as inflammation can increase. Yoga also uses resisted exercises, but the nature is different. Yoga

does not provide mechanical or repetitive movements. It is improper to classify yoga as isometric, as both isometric and isotonic strains are given to a muscle at a single point in time. The geometry is also different, as is the movement. All standing poses are important. Each tones up a different portion of the knee joint and the stress and strain offered by each pose is different. Standing poses strengthen, realign and massage the cartilages and improve weight bearing. The use of the foot rest with the foot dorsi-flexed and the knee locked, and the ascension of the quadriceps strengthen the knee. Alignment is very important in performing these poses which is absent in physiotherapy exercises. Inversions teach proper alignment of the knees which is more difficult to achieve than in the standing poses. The muscles become strong as the anti-gravity action is used. Variations are also helpful. Padmasana and Virasana, with their massaging actions, are highly beneficial to tone up the cartilages. The supporting muscles of the knee joint are also made flexible and massaged. This relieves pain. Back bends educate the knee in the most intricate manner way. As it is more difficult to direct and control the muscles of the knee in these poses, great skill is needed. Supta Virasana preceded by Viparita Karani relieves the strain of constant running. To avoid recurrent injury to the cartilage and to the same knee, the sport must be practiced using both legs. The player will benefit if Virasana and Padmasana, which massage the joints, are practiced before and after each game.

American football This game has a high propensity for injury. Players have permanently damaged themselves with transection of the spinal cord. Strong concepts of safety have, no doubt, changed the face of the game, but injuries still occur. Padding provided to all parts of the body is not the answer. It might be questionable to play a game if one knows that the chances of injury are high. A game should not result in recurrent injuries. Head-on collisions have caused fractures of the cervical vertebrae due to excessive loading on the column causing paraplegia. Injuries to other parts of the body also occur depending on the site of impact by the opponent. Legislation has dramatically reduced the incidence of injuries in this sport. Barring injuries, the main concern in this sport is one of exhaustion to the nervous system — to the senses. Using the crepe bandage on the face, inversions, standing inversions, seated forward bends, Supta Virasana, Viparita Karani are helpful to relieve strain in different parts of the body. Pranayama relieves strain on the mind.

Polo The most obvious feature is the repeated bend of the spine to the same side. The other is the constant use of a single arm. The load on the spine in this game is considerable as the player has to bend from a height. The left side of the spine is overstretched. The neck muscles are also used lopsidedly. The intercostal muscles on the dominant side are also constantly compressed. The inner groin and the adductors on the dominant side of the thigh are overused. The left groin and adductors are compressed.

The practice of hand stand and elbow balance is needed. The remedy for the spine is to practice lateral bending poses like Trikonasana and Parsvakonasana, and standing rotational movements like Parivrtta Trikonasana and Parsvakonasana. Parivrtta Janu Sirsasana is very valuable. Baddha Konasana and Upavishta Konasana are essential to ensure even usage of groin muscles. Back bends are a must, as the spine is always bent forward. These poses also squeeze the kidneys and prevent excess mobility of the organs (a condition known as ‘floating kidneys’) due to constant riding. To make up for uneven arm usage, practice bouts with the left arm are essential. The lungs, abdominal organs and pelvic organs are compressed in the tilt of the body. All standing poses, with emphasis to the side opposite the compression, are beneficial.

Uttanasana with foot rest elastisizes calf muscles and lower back.

Uttanasana with head on stool relieves fatigue, soothes mind, cools the system, energises heart and lungs.

Trikonasana with heel pushed into wall stretches calf muscles, relieves cramps, prevents tears and tendinitis.

Virabhadrasana III on prop provides suppleness, useful for sprinters.

Sarvangasana with belt elastisizes deltoids, relieves shoulder aches, recharges entire body.

Use of belt on arms relieves scapular pains, prevents over stretching of shoulders, makes shoulders supple.

Reverse namaste gives flexibility to wrists, shoulders and elbows, prevents and heals rotator cuff injuries.

Urdhva Mukha Svanasana prevents inflammation of elbow joints. The box under the hands helps a stiff person to bend back easily, while resting the hands on a slanting plank helps stiff wrists.

Neck on rope prevents overuse injuries, habitual strain and future degenerative changes from repetitive movements.

Trapezius traction prevents and relieves nodules on the muscle, relieves overuse injuries.

Viparita Karani on pillows removes systemic fatigue, relieves leg pain and fatigue, improves circulation without strain.

Holding window bar, standing erect, relieves shoulder pain, provides spinal elasticity.

Supta Virasana on pillow relieves aches, general fatigue and pain in the calf, rests heart and lungs.

Hasta Padangusthasana with ropes for hamstring flexibility with alignment, prevention and relief of backaches, habitual back injuries and hamstring tears.

Holding window bar squatting elasticizes shoulders, heals repetitive injuries.

Bharadwajasana on chair prevents repetitive injuries and spinal problems.

Double rope back bends with arms behind (left) and above the head (right) elasticize shoulders, heal repetitive injuries, relieve shoulder pain and provide spinal elasticity.

Dog pose stretches calf muscles, lower and mid back, prevents and cures habitual injuries and Achilles tendinitis.

Upavishta Konasana with blankets is for groin flexibility, adductor and hamstring flexibility with alignment, preventing tears in groin.

Krounchasana with belt prevents habitual injuries, makes hip joint, hamstrng and groin flexible.

Supta Padangusthasana with leg against wall for hamstring and adductor flexibility, strengthening hip joint and improving blood circulation.

Baddha Konasana with bolster for groin and hamstring flexibility.

Padmasana and Virasana make groin supple, relieve and prevent knee injuries, cartilage tears, aches and pains, calcaneal spur, plantar fascitis and over use injuries.

Billiards The body is held in a constant angle for short periods. The position of the leg, arm, spine and neck is so awkward that postural problems can set in very easily. One leg is sometimes placed back and the other forward and this automatically tilts the pelvis. One arm and shoulder are stretched forward and the other drawn back and the elbow constantly bent. The deltoid muscle of the striking hand is contracted in the outer aspect. The arm pit and the wrist of the stretched arm are overused and so is the latissimus muscle of the extended arm. The trapezius of the extended arm is constantly contracted. The neck and the eyes are forced to look in an awkward manner in relation to the rest of the body. The spine is rotated to the right and tilted to the left or constantly bent forward. One side of the abdomen is contracted and the other side stretched. The legs suffer exhaustion due to long hours of standing. The main concern is that the postural imbalance thus created will give rise to chronic pain in different parts of the body. Modification in the playing technique is not feasible—if the table were higher, the strain would be less on the arms and the back. The only other solution is to practice corrective and compensatory

movements to right the postural imbalance. Standing postures with emphasis on lateral bends to the right side, rotational movements oriented to the left, are helpful to overcome the constant one-sided usage of the body. Parivrtta Janu Sirsasana is very beneficial. Inversions relieve the long hours of standing and correct the tilt of the neck. Posterior hand stretches on the window and the wall ropes, along with Hand stand and Elbow balance, are essential to relieve the stress of asymmetrical usage. The practitioner should work the muscles of the deltoid and triceps area of the left hand more consciously than the right side. Both sides of the chest should be attended to in all poses, particularly back bends. If the player is attentive to this, likelihood of suffering the effects of chronic asymmetrical usage is less. The stooped posture of the game is similar to practicing a half Uttanasana always, without countering it. Hence, the person will experience the effects of a semi-forward bend. The organs are always pressed. Back bends are essential to stimulate the lungs and heart, as the body is always bent forward, compressing them. Practice of Viparita Dandasana on the rack before the match will refresh the mind and the eyes and prevent exhaustion. Pranayama with the bandage refreshes the sense organs.

Boxing In spite of knowing, experiencing and realizing the injurious nature of boxing, the sport goes on. There have been attempts to ban this game. The boxer is pressurized to vent all the fury on the opponent. It is not rational to allow two human beings to participate in a sport that involves hitting each other with a high risk of injuries. It is well known that professional boxers can suffer from the ‘punch drunk’ syndrome. The skull is hit with a tremendous force which results in the brain being pushed towards the opposite side of the skull (if the blow is from the left, the brain is pushed to the right). The result is that the brain gets hammered repeatedly between the two sides of the cranial cavity. In the long run, the neurons waste away due to the chronic impact and the person suffers from slurred speech, lack of coordination, gait disturbances, and dulling of intellect — a Parkinsonian complex. The senses and the mind also take a constant pounding. The boxer, though appearing healthy, is overdeveloped in the upper body. The manner of crowding the hands close to the body prevents the muscles of the hands and the torso from stretching. The hunch is often evident on the dorsal spine. Healthy breathing is hindered. The chest is constantly hunched, pressing the intercostal muscles together. The abdominal muscles are over hardened, creating a stiff diaphragm. All the tissues of the body are tight and inelastic. The legs are constantly on the move and exhaustion results. The muscles of the arch of the foot are under constant tension. All categories of asanas benefit the boxer. For the spine, back bends take preference over forward bends. Asanas that provide proper extension of the arms, like hand stand, elbow balance, Urdhva Dhanurasana and Dog pose, are all useful. Working with the wall ropes to ensure extension of the spine is very helpful to expand the frontal torso. Uttanasana, Dog pose, seated forward bends and head stand and shoulder stand along with Viparita Dandasana are very valuable to soothe the mind, the senses and the brain, disturbed by the constant pounding. Setu Bandha Sarvangasana and half Halasana rest the frontal brain which is overused by boxers both physically and mentally. All these

asanas are to be done with the bandage to soothe the brain cells which undergo so much stress. Pranayama done supine (with the head on pillow) is beneficial. The head rest soothes the mind. Prolonged exhalations are most important to relieve tension in the brain. This also removes the strain of getting hit on the skull and the person feels lightheaded after practice. The use of a bandage on the facial muscles is necessary.

Wrestling An olden day sport which was relatively not so violent on the body and the psyche, wrestling has become harsh today. There are many styles and a common factor is that the body has to be fattened and kept heavy. Body contact being inevitable, injuries result. The mildest variation is Sumo wrestling, where the aim is to push the person out of the ring. Sumo wrestlers, being grossly overweight, suffer from diabetes, hypertension and premature degenerative disorders of the spine, hip, knee and ankle joints. The sensitivity of the body suffers due to overeating, which assumes enormous proportions. Once the person retires, the inactivity, combined with the overweight, destroys the body very easily. Premature death is likely. Wrestlers frequently change their diet to qualify for a particular category. Studies have shown that various methods are used, such as fasting, vomiting, laxatives, diuretics, sauna, rubber sweat suits, or heated wrestling rooms. Some of these methods induce weight loss by dehydration. The wrestler has been known to gorge on food and fluid after the event, only to repeat the process of weight control for the next selection event. All this is extremely harmful to the body metabolism. Natural methods of weight maintenance are healthier. This ‘weight cycling’ has been shown to be associated with a higher incidence of coronary heart disease and other metabolic disorders. All parts of the wrestler’s body are stiff and, even if flexibility programs are followed, there is difficulty of movement due to the sheer bulk of the tissues. Wrestlers often cannot squat on the ground or raise their arms freely overhead. The right perspective towards this event is to avoid fattening the body at all and use safe techniques while fighting. All asanas are useful. Standing poses protect the knees and hip joints. Asanas which open the groin ensure proper alignment and tone and a healthy blood supply.

Weightlifting The whole body is subjected to strong forces with emphasis at certain points. The muscles of the weightlifter increase in size and cross sectional area (Tesch and Larsson, Eur.J.Appl.Physiol., 49: 301-306, 1982). This is an adaptive situation. Yet it is unhealthy, as the other organs are affected in the process and the stress induced on the body is asymmetrical. It has been found that weightlifting is a strong stimulus for bone formation and mineralization (Brain, William et al, MSSE, Oct 1993). Endurance training does not produce such changes. The weightlifter has to have a high calorie diet to qualify for certain selection categories. Manipulating dietary factors might be harmful to the body. By mere observation, one can appreciate the strong nature of the bones of the weightlifter. The heavier the weight lifted, the brighter the chances of topping the competition. The danger of overtraining is thus ever present.

The hypertrophy of bone is a natural adaptive change, as heavy loads have to be lifted. Once deconditioning occurs, the bones might return to the original density. Although the weightlifter can bear enormous loads, the excess weight gained is a constant strain on the heart, lungs and abdominal organs. The arms are out of proportion to the rest of the body and strained excessively, especially when the person strives to break records. The cervical spine is also overused. The spine is loaded heavily and the pressure on the discs is considerable. The increase in intra-abdominal pressure is transmitted to the back and, if a belt is not worn, a ruptured ligament or disc often results. Chronic low back pain due to training injuries and over usage due to excessive loading, are common. The ankles, knees, thighs and hips are subjected to very heavy strain. The weightlifter has to wear knee and ankle caps to protect the joints. The thigh muscles are overdeveloped in lifting heavy loads. The joints of the lower limbs always turn outward at the moment of lifting. This can affect the medial ligaments of the ankles, knees and hips. Studies have shown that the left ventricular mass is greater in weightlifters, related to the maximum aerobic capacity (MSSE, April 1993). During the lift, due to compression of the intra-thoracic organs, the left ventricle can undergo hypertrophy (in response to persistent loading). The blood pressure can rise to enormous levels at the time of the lift. In the long run the lungs are also compressed, hindering free mechanisms of inspiration and expiration. The shoulders and the accessory muscles of the neck tighten, breathing is labored and the diaphragm tight, the eyes are congested. The entire cardiorespiratory system is always under tremendous tension. Due to the rise in intra-abdominal pressure, the organs are compressed and the cells are kept in a ‘shrunken state’ with reduction in blood circulation. The gall bladder, liver and pancreas are pressurized. The abdominal aorta is compressed. Colonic pressure can rise to several times more than normal. The kidneys and pelvic organs are stressed. The mind is under tension and the neurons are under terrific strain at the moment of the lift. The weightlifter may be strong but according to yoga, circulatory and nervous energy cannot flow freely. Movements should be graceful and light, not heavy and sluggish. Practice of yoga is highly beneficial. The even usage of the body during asanas prevents regional over stimulation of the bone. The neck and arms are benefited by inversions, Hand stand, Dog pose done both ways, and Elbow stand. The elbows and wrists are kept well aligned and supple by Urdhva Hastasana, reverse namaste, Dog pose, Hand and Elbow stand. The mid and lower back and the ligaments and muscles of the lower limbs are kept soft and supple by standing poses. The use of the horse prop is essential to help the heavy weightlifter perform the standing poses. As the muscles may be oversized and stiff, it may be physically impossible for some to achieve flexibility without props. Twisting poses are very valuable for softening the hardened muscles of the weightlifter. Back bends done passively relieve strain on the back by giving rest to the posterior spinal muscles. Forward bends improve blood supply to the posterior spinal muscles which are always constricted during weightlifting. The strain on the heart, circulation, blood pressure and the lungs is prevented by regular practice of standing and seated forward bends (with the crepe bandage on the face), in a modified way to suit the lifter. Forward bends done passively with the bandage relieve strain on the senses and the sympathetic nerves. Back bends promote excellent expansion of the intra-thoracic organs. The abdominal organs also benefit due to easier blood flow. The diaphragm, which tends to be stiff in weightlifters, is softened by back bends and twisting poses. The pelvic organs, which are pressurized

in the squatting position, get relief from Baddha and Upavishta Konasana. It is difficult to rationally integrate yoga and weightlifting for persons interested in both the arts, for the mechanisms are different; but the practice of yoga is needed to prevent the side effects of the latter. To relieve tension on the senses, mind, lungs and heart, Ujayii pranayama done supine is helpful. During weightlifting the person is forced to automatically perform Kumbhaka (as a lift is done). This restrains the diaphragm and retards free circulation. The nerves become tight. Prolonged exhalation with a bandage on the face relieves this strain.

Gymnastics One of the most graceful and stylish sporting events enjoyed by many, but we are not aware of the stress on the body in the training period and the effect, during the pre-pubertal years, on the healthy growth of the body and on menarche in females. The gymnast suffers later in life when it would be difficult to reverse many of the side effects. Weight has to be kept optimum and this can affect the nutritional status and the reproductive system. Female gymnasts have broader shoulders than normal women of their age and the pronounced female curve of the hips is altered. Most teenage female gymnasts show poor breast development. This is due to training the body at a tender age. Though studies have shown that the petite stature of the female gymnast is more often due to selection than the effects of training, premature high intensity training (on the delicate cartilages and joints) of the child is not advisable. The strong traction forces working on the unossified bones can hinder proper development (Herring, Nilson, Clin. Sports Med., 6: 225-239, 1987). When a bone’s capacity to repair itself is overcome by such strong forces, stress fractures result. Male gymnasts are also narrower in the lower half of the body. The arms tend to be overdeveloped. The most detrimental aspect of the training is that of imposing excessive flexibility and loads on tender bodies. Yet another factor is that of constant back bend practice. Most of the time, the performance of gymnasts is punctuated with extension movements. The stretching movements of the spine and the legs are often done without proper alignment. This leads to ligaments and muscles that are looser than normal. Sprains of the lower lumbar muscles are common. The spine is constantly bent backwards. The lower extremities account for 60% of injuries and the upper for 25% to 30% (McAuley, Hudash, Shields, Am.J.of Sports Med., 15: 558-565, 1987). Knee disorders due to outward turn of the foot during movements are common. Jerky movements are used for the upper arms and lower limbs. Hence, recurrent injuries to the wrists, knees and ankles force the gymnast to wear ankle and knee braces to maintain stability. As the event is fast paced, there is often no time for the gymnast to adjust the joints and muscles and optimize the load to different parts of the body. For example, the person excelling on the Roman rings has overdeveloped arms to support the event. This inequality is the main cause of tears and sprains. Moreover, during performances, the mind is under great tension. The same person performs better under non-competitive practice conditions. This problem is common for all performance artists, but in the case of the gymnast the consequence could be serious physical injury. To summarize, the two common causes of injury to the gymnast are the nature of the sport and the over intense training

inculcated at very short intervals. Hours of practice are needed. This results in loss of family and social interaction, which are essential. Yoga helps gymnasts understand the principles of alignment in stretching and contracting the muscles, joints and ligaments of the body. It helps them to balance movements of extension and flexion for all parts of the body. Refinement of the intelligence with regard to the body and mind through yoga is beneficial. The yogi is the divine gymnast In yoga, cells are kept in alignment and then balanced. Poise is constantly re-defined every day, in the same pose, so that stagnation never occurs. Hand stand and Elbow stand help in the proper alignment of the arms. The spine, hip and the knee joints suffer premature wearing, which can be prevented by standing poses. The gymnast learns the right method of alignment by these poses. Inversions are useful to give rest from the stress of performances, and forward bends quiet the senses and also allow better stabilization of the body which is constantly bent backwards. Back bends give endurance both to the body and the mind and, along with Setu Bandha Sarvangasana on the props, rest to the mind during emotional depression. Back bends done along the principles of gymnastics constitute hyperextension of the spine. The dorsal, spinal and the gluteal muscles are not used properly. Yoga teaches the correct geometry of these poses to the gymnast. The alignment of Baddha and Upavishta Konasana, and Samakonasana along with Hanumanasana has to be understood carefully by the gymnast. The gymnastic split is often not executed properly as the sciatic nerve is under pressure due to the incorrect position of the piriformis muscles of both the hip joints. Yogic techniques teach the right method of these asanas which prevents injuries. Pranayama is useful to relieve stress on the mind and senses.

Cycling The striking feature of cycling is the hypertrophy of the thigh muscles due to the posture adopted to break wind resistance — the convex spine and the constantly arched cervical muscles. The crouched posture affects the locomotor system. The upper limbs are under constant flexion and tension. The sport leads to an overdevelopment of the lower half of the body. The knees and ankles are overused. The hip joints are also taxed. The abdominal muscles are hard and remain constantly contracted. The muscles of the posterior aspect of the body are constantly spread out. The anterior surface of the spine is always contracted. The cervical column is arched, sometimes causing neck ailments due to the contracted state of the cervical muscles. In short the entire spine is affected. The endurance capacity of the heart and the lungs is, no doubt, very good. But the constant hunch of the spine tends to contract the chambers of the heart and the anterior surface of the lungs. The posterior surface of the lungs is always stretched open. This leads to lopsided stimulation of the organs. The abdominal and pelvic organs are always pressed in the posture of cycling and the stimulation of stretching, as in back bends, is lost. Healthy blood cannot flow to these organs. With the constant pressure of the seat to the perineal area, the genital nerves get over pressurized. This can result in erectile dysfunction in the male and, in the female, interference with proper contraction of the

muscles of the vagina and the perineal muscles. The groin muscles, always being held tight, interfere with healthy circulation in the pelvic organs. The skull being in a bent position, the nervous system never has the chance to get soothed (as in forward bends). Yoga is very helpful to the cyclist. Hand stand and Elbow stand improve blood circulation and remove unnatural strain in the hands. The shoulders are stretched by back bends. Standing poses help the lower limbs and spine to remain resilient and supple and the hamstrings derive better blood flow as they are stretched well. Inversions and forward bends ‘cool’ the ‘heated’ brain. Back bends open out the contracted chest and stimulate healthy and effortless blood flow in all the organs in the thorax, the abdomen and the pelvis. This stimulates the nervous system. Baddha and Upavishta Konasana stimulate blood flow in the pelvic and genital areas and relieve congestion. The genital organs feel re-vitalized, the practitioner experiencing a sense of warmth and lightness in those areas. Viparita Karani and Supta Virasana with pillows between the calf and thigh muscles (see illustrations, page 98) are very helpful as the latter massages the tired muscles without any disturbance giving rest and relief to the aching leg muscles. Pranayama is helpful to prevent onset of fatigue. All varieties can be done. Supine pranayama relieves the stooped posture and opens out the chest, allowing free breathing. Immediate refreshment occurs in the frontal brain. Kumbhaka performed with an erect dorsal spine builds up the endurance needed. As the eyes have to look upward constantly, the sense organs are pressurized. The use of the bandage during pranayama relieves this stress.

Motor cycling The body posture is somewhat comparable to cycling. The spine is always flexed. The head has to bear the weight of the helmet in the extended position for many hours. The noticeable feature is the widening of the inner groin muscles in the flexed position. The body does not suffer as much strain as in manual cycling as the muscles are not physically worked. The constant maintenance of the flexed posture can induce changes similar to those in cycling. The added feature is the danger of a skid and fall. If the motor cyclist follows the guidelines of asana practice given for the cyclist, postural problems can be avoided. Actually, the motor cyclist is always doing a fairly complete forward bend! Hand and Elbow stands work on the arms and stretch them out, improving the blood supply. Standing poses increase the blood circulation in the thoracic organs and legs, especially in the latter which are in dire need of fresh blood due to the constant flexion of the leg. The spine is well stretched and relieves the strain of the flexed posture. Inversions give relief from fatigue and remove de-oxygenated blood from the congested areas. Forward bends soothe the brain which is under the helmet all the time, and the sense organs are also given relief. Supta Padangusthasana and Hanumanasana push healthy blood into the constricted legs. Back bends invigorate all the organs by reversing the posture of motor cycling. Sitali pranayama done before the event prevents excessive rise in temperature due to the sun exposure and the leather suits worn. Pranayama with pillows relieves nervous exhaustion. At the end of an event, practice of Viparita Karani relieves fatigue immediately by opening the circulation to the inner organs and removing de-oxygenated blood from the legs. In all these, the relevant nerves are also toned.

Swimming Both the sides of the body are used fairly symmetrically. Swimming precludes the harmful effects of impact as in land sports. A person with a low back disorder is permitted to swim (not when in acute pain) as the buoyancy prevents stress on the back. Yet, there are other problems. The first concern is body weight maintenance. This can, in turn, lead to nutritional deficits. In women, certain areas tend to be hypertrophied and over exercised. The excessive usage of the pectoral muscles causes loss of fatty tissue in the breast and most female swimmers show poor breast development. The distribution of the female body fat is also affected and the general contour of the body leans towards that of a male. The leg and calf muscles hypertrophy; the shoulder and posterior thoracic cage muscles enlarge. The heart and lungs are well toned. The cardiovascular efficiency is as good as in any athlete on land. One of the greatest benefits is the healthy development of respiratory power as the head dips in and out of water. The glandular system can get exhausted with overtraining. The professional swimmer’s lipid profile does not appear to undergo any special changes because of swimming. Yet, during the exercise period, the level of LDL cholesterol decreases. The skeletal changes require particular mention. Though swimming is considered a non-weight bearing exercise, Orwoll and colleagues (Arch.Intern. Med., 149: 2197-2200) found that the density of the radius and vertebral area was higher in men who swam regularly than in those who did not. The increase in bone density is due to the high intensity muscular activity. Professional divers risk injuries to the eyes and neck. The intensity of the impact during diving can affect the retina. The eyes and ears are irritated due to the constant influx of water. The hands and legs are used in a different manner than on land. The intense heat of the muscular activity opens the pores of the skin but, as the water is cool, an inhibiting effect occurs on the sweat gland function. This is a strain on the system as the heat has to be dissipated. Another concern is that of electrolyte and temperature disturbances as the swimmer alternates between land and water. Further, as most of the time is spent in water, the muscles get used to a different type of stimulus with respect to the G force, and the capacity of the body to bear physiological stress and strain on land may alter. To prevent this, it is essential that some sort of exercise be practiced on land for a certain period every day. This should be a non-stressful exercise to help recuperation. Asanas like Hand stand, Dog pose, Elbow balance, back bends, teach the proper stretch of the arms and nullify strain. Inversions protect the eyes, sinuses, ears and legs from fatigue. Supta Virasana relieves cardio-respiratory fatigue. Forward bends expose the body to the external atmosphere and allow time for healthy perspiration. Back bends make the body sweat to dissipate the internal heat. They also provide stamina. For exhaustion of the legs, Viparita Karani and Supta Virasana are valuable. The groins, which are constantly constricted, are benefited by Baddha and Upavishta Konasana. Pranayama helps maintain healthy coordination between exhalation and inhalation, which is very necessary as the upper respiratory organs dip in and out of water. It prevents stress on the respiratory

organs. It also helps to promote excellent drainage of secretions from the sinuses, upper and lower respiratory tracts. Kumbhakas enhance healthy endurance for the water sport.

Skiing The earliest record of skiing is around 2500 BC. Since then, much sophistication has developed in the availability of gadgets for skiing. Many new techniques have been evolved. The physiological changes in cross-country skiing are similar to endurance training. Here, large groups of muscles are put to work. The amount of oxygen consumed is high. The cardio-respiratory fitness is similar to that of endurance athletes. The heart shows an increase in the thickness of the left ventricular wall. The muscles of the legs, however, are shown to have a lower oxidative capacity than that of long distance runners. Even though the effect of impact is avoided in skiing, the shoulders, knees and back are excessively stressed. The major areas of stress build-up are in the hands and shoulders, spine, groin, knees and ankles. The hands are always used in a flexed manner and never stretched out. The shoulders are constantly used in a one-sided manner. The spine is bent forward and, combined with the pressure on the groin; this reduces circulation in the inner organs. All the spinal muscles suffer fatigue. The knees and ankles suffer ligament strains and tears due to the constantly bent position. The situation is worse if a slip occurs. Although high impact is absent, wear and tear of the cartilages occurs due to over usage. The lungs and heart are strained to the maximum. Hand stand, Elbow stand and balancing poses teach proper extension of the arms. The skier can practice all standing poses to prevent degeneration of the spine and the lower limbs. Inversions combined with Supta Virasana give relief to aching legs. Baddha and Upavishta Konasana provide for healthy pelvic blood flow. Hamstring stretches relieve the constantly compressed muscles. The spine is helped by all asanas. Back bends are essential to relieve the stress of the constant stoop and provide cardio-respiratory toning to help prevent easy exhaustion at altitudes. Back bends on the ropes are ideal for the beginner to secure quick relief. Supine pranayama relieves fatigue and all the varieties can be practiced to improve endurance.

Rowing The rower is always bent forward. The parts of the body that suffer are the spine, groin and hands. The constant flexion has, in some instances, produced fatigue fractures of the vertebral bodies. Over the years, the spine can suffer premature degeneration due to repeated flexion stresses. The knee may be kept semi-straight or straight and, if the latter, the lumbar region suffers strain. The dorsal spine is excessively bowed. The chest often caves in. The buttock bones become sensitive to pain due to constant pressure. The muscles of the arms face the stress of asymmetrical usage. The action is always of a closed nature and this restricts healthy blood flow in the arms. The knees need to be stretched out. The thoracic, abdominal and pelvic organs are pressurized in the same direction every day. The heart and lungs, being subjected to the effect of a forward bend, do not enjoy fresh blood flow. The lungs cannot draw in fresh oxygen. The posture is a load on the circulatory and respiratory systems. The

intestine, gall bladder and pancreas are pressurized, restricting the flow of fresh healthy blood in the abdominal aorta. The pelvic organs are compressed and, in the female, undesirable pressure on the ovaries, the uterus and its supporting ligaments is produced. This reduces the outflow of the menstrual discharge. Use of Hand stand, Elbow balance and back bends teach proper extension of the arms and maintain suppleness and blood flow. They prevent misalignment and over usage of the same group of muscles. Standing poses give relief to the spinal muscles and lower limbs of the oarsman. Baddha and Upavishta Konasana open the constricted groin area, improving blood circulation. Inversions cool the brain which is constantly in the flexed position. They also relieve the circulatory stagnation by allowing fresh blood to enter all the inner organs. Setu Bandha Sarvangasana refreshes the heart, lungs and spinal muscles due to its concave geometry and improves the circulation in the thoracic organs. This gives greater energy to the rower as the lungs secure rest and can draw in greater quantities of oxygen. Practice of back bends provides relief to the spinal muscles, the thoracic and intra-abdominal organs. Passive back bends on the props are useful to relieve cardio-respiratory fatigue. Pranayama enhances endurance and reduces strain on the sense organs. In the ultimate analysis, the rower cannot afford to ignore the benefits offered by yoga.

The overtraining syndrome This is a physiological condition of excessive and prolonged fatigue due to training at high intensities and without periods of rest. The symptoms include fatigue, loss of weight, elevated blood pressure, rapid pulse rate, digestive dysfunction, insomnia and some emotional disturbances. Studies have demonstrated both elevated and depressed levels of catecholamines in the system. If a person over trains, it is natural that the adrenal glands will be overworked. Another important factor is ‘sports anemia’. Endurance athletes appear to have low iron content in their bodies (this can occur with any kind of sporting event). There can be no generalization as to the limits of endurance permissible for each sport, as each individual is different and guidelines have to be personalized. Medicine tries to give a general guideline for all human beings. Yoga believes in attending to every individual and advising each according to the needs. The human body may be the same, but the mind is different and conditioning varies. In addition, there is the issue of the psyche with its innumerable layers of consciousness, all of which play an important role in determining the behavior of an individual. Medicine is now increasingly recognizing the role of the mind over the body.

Nutritional requirements Food such as fruits and vegetables, animal products like milk and meat, grains and legumes, and foods containing fat make up the diet of an endurance athlete. There has always been an obsessive belief, in the sports world, that a vegetarian diet cannot make a healthy sportsperson. This is erroneous. A balanced diet inclusive of all parameters will prevent undernourishment in the athlete. Ragi (finger millet) is very good as its high calcium and energy content is valuable to the athlete. Food should be easily digestible; food high in carbohydrates is desirable. This is digested the fastest, followed by protein and fat.

Adequate energy is the most important requirement of the sportsperson. Any unused energy is stored as fat in the body. Carbohydrates are the preferential fuel for high intensity work, as they enrich glycogen stores. The recommended daily intake of carbohydrates is around 500 to 600 gm. Ingestion of carbohydrates before and during events has been shown to improve performance. After an event, ingestion of fluids rich in carbohydrates replaces muscle glycogen. The fat content is kept as low as possible to prevent atherosclerosis. Liquid foods are used up faster than solid foods. To prevent dehydration, adequate fluid is to be consumed before, during and after events. To ensure a high carbohydrate intake, many athletes adopt a near vegetarian diet. It has been found that the natural killer cell activity of the immune system is higher in vegetarians. Athletes will, in the long run, benefit by a vegetarian diet. Though studies have shown that switching over to a vegetarian diet has not adversely affected endurance performance, these have to be carried out for longer periods before any firm conclusions can be reached.

Mental stress The inner anxiety to maintain the high status won over years of hard struggle makes the mind get attached to these achievements. This will lead to agony if the person is not able to maintain this position. In a long career, this continued stress on the mind can cause a nervous breakdown. This is all too common today. In order to avoid this, intense training is needed for the sportsperson to have an attitude of total detachment from the fruits of labor. Here, yoga can show the way towards mental detachment and consequent freedom. The sports professional should ensure some means of relaxation in daily life. In the pressure of achievement, the individual could lose all spontaneous interest in the game and be involved in it mechanically, as a performing machine. Training centers all over the world must provide an atmosphere of quietude and opportunities for recuperation. Activities of a mechanical nature lead to boredom and depression.

The use of drugs If the athlete has failed to achieve set standards, drugs are used to combat the situation. Though their harmful effect is well appreciated, the desire to achieve name, fame and position drives some to indulge in the use of drugs. This is a highly contradictory state where the body is trained for fitness, but with the poison of chemicals inside. It is a great delusion that glory must be achieved even at the cost of physical and mental health. The drugs create either elation or depression, and there is no certain rule regarding their effects on behavior. In addition, failure to succeed further pushes the athlete into depression, thus worsening the situation. The professional and economic status of athletes depends on the sports they play, and clarity of mind is essential in their approach to competition. A variety of ergogenic aids have been tried in the desperate need to be at the top — alcohol, amphetamines, caffeine, cocaine, electrical stimulation, gelatin, growth hormone, massage, vitamin supplements, bee pollen, HCG, adrenaline, organ extracts — though a majority of these have really not provided any tangible benefits. The Olympic Committee has cited a banned a list of drugs and this includes psychomotor drugs, drugs that stimulate the sympathetic nervous system, narcotic analgesics

and anabolic steroids. Anabolic steroids This group of drugs is used by many athletes today. The increasing level of competition has led to sophistication in the manufacture of drugs in the hope that its usage would be impossible. The worst damage is induced by anabolic steroids, which resemble the hormone testosterone needed for cell growth and differentiation. Protein synthesis is increased with anabolic steroids and wasting is reduced. The American College of Sports Medicine has maintained that health risks of such drugs outweigh the benefits obtained. Some of the side effects include liver toxicity, high blood pressure, elevated lipid profile, nervous tension, altered electrolyte balance, decreased spermatogenesis, increased urine volume, increased or decreased libido, acne, sore nipples, nasal bleeds, muscle cramps, disturbed thyroid function and increased activity of the sweat glands. Growth hormone The properties of growth hormone are described in the chapter on the endocrine system. Basically, the build-up of body protein is stimulated with an increased entry of amino acids into the cells. The side effects include gigantism with the use of this hormone. Amphetamines This is used in cycling, football, track and field events, to prevent fatigue and to improve endurance, speed, power and reaction time. The mode of action is to stimulate the sympathetic nervous system with increased wakefulness and general overdrive. No definite benefit has been observed by the ingestion of these drugs and side effects include tremors, insomnia, and dry mouth, loss of appetite, irritability and cardiac rhythm disturbances. Experiments with nutrition The Greeks were known to eat red meat in an effort to improve their prowess. Since then, a variety of health products have been experimented with in order to improve the physique of athletes in terms of mass, weight, tissues and stamina. Carbohydrates, vitamins, have all been used without any proven benefits. On the contrary, these affect the cells of the body in the long run. The professional athlete today is not into sporting activities to improve health, but to prove to the world the capacity to achieve spectacular success. Good health was a by-product in the process of training, but even this is being jeopardized by overtraining and drugs.

Increased life expectancy of world class athletes In spite of the inherent side effects of sports, athletes do remain healthy and studies have shown that

they have an increased life expectancy (MSSE, Feb 1993). This is due to the high levels of fitness. It has been constantly emphasized that physical activity prolongs life span. The factors that enhance life span are many and habitual physical activity is only one of them. The others are a healthy diet and minimizing stress and having the right attitude to challenging situations. Does one have to be an endurance athlete to enjoy an increased life span? With the grace of God, if one follows the rules of healthy living according to yogic texts, and asanas and pranayama are practiced every day, one’s life span can increase (to a point). It is very common to find yogis in the region of the Himalayas living to over a hundred years and possessing an excellent quality of life. The reason has been attributed to their practice of yogic techniques and serene living. Their stress-free life is not because they are remote from human habitations, but because of their calm approach living. The yogis of India never practiced endurance exercises, yet their life span has been very long. This has been so for centuries. Health is not just due to a single causative factor; it is always a combination of the right diet, adequate exercise and an equanimous attitude in life. Each parameter has its own role to play in human physiology and health, as mentioned before, is a summation of all three. The human body has a tremendous capacity to adapt to any physiological situation. The yogis in the Himalayan ranges remain at high altitudes for years, bare-bodied, without any deleterious effects. The fact that the yogis can control the autonomic functions of their bodies has been observed time and again. The power of the mind over matter has been repeatedly demonstrated. All we need to do is to respect our bodies and treat it well as long as we live.

Patanjali and the athlete For today’s athlete, ahimsa is much needed. The athlete must refrain from consuming any drug that might affect the body — this is ethical discipline towards oneself. The overtraining syndrome must never occur. The practice of athletics must be one of purity in all facets and, when this is strictly followed, satya exists. In the niyamas, saucha is strictly required if the body is to excel in sports. The athlete must strive to maintain the inner purity of the body by practice of yoga, so that the system will serve for a longer period with a healthier quality. Dejection should not be allowed to possess the mind. In the face of failure, the athlete must strive to maintain equanimity. This is easier said than done but, if a person lives by the teachings of Patanjali at least to some extent, the spark of niyama will be ignited. Tapas is what the athlete practices naturally. In order to achieve, one strives with single-minded concentration. In addition to this, if the mind has an inner quietude, tapas blazes with greater intensity. An example I could give is that of the great martial artist, Bruce Lee. He had the quality of tapas to a great extent. He was so involved in his practice that perfection was manifested. Very few human beings achieve such spectacular performances. Swadhyaya is helpful to the athlete to discover the inherent faults of the body and mind. Unless the reactions of the body and mind are reflected upon and adjustments made, refinement in technique will not result. This faculty of study is a never-ending process to prevent stagnation in practice. In

athletics, due to the fast pace of events, there is little time to perceive the movement of the individual parts of the body. Here, analysis of body motion with video recordings and other techniques help. In yoga, the mind is trained to reflect from moment to moment, but not to be caught in the movement of the moment. The trained mind is in a state of quietness which makes it razor sharp to root out imbalances. This refines the practice. Ultimately, the result of the event is not in the athlete’s control. A sense of detachment from the fruits of labor is needed to preserve equanimity of mind. This is the state of Ishwarapranidhana. The practice of pranayama leading to withdrawal of the senses (pratyahara) relieves mental and physical strain. Pratyahara prevents excessive build-up of stress in the body of the sportsperson and removes the accumulated stress. Stress is ever there, it is needed for proper stimulation of the body and mind. If the response is in excess or inadequate, the person suffers. The level of stress has to be optimized. The last three stages of yoga — dharana, dhyana and samadhi — help the athlete to bring the body and mind to a state of total poise and stability in all the sheaths. Dharana is always used by all. Yoga teaches the sportsperson to strengthen this faculty when the asanas and pranayama are practiced. In yogic practice, the self and the cells are connected. This leads to introspective action. According to Patanjali when concentration is refined and is continuous, it becomes meditation. The state of meditation helps the athlete to remain unaffected by results but to act for the moment. This merges into samadhi, through which athletes perform without being affected in any manner, physically or mentally. When the athlete is so absorbed in the art, perfection flows; the distinction between the self and the sport is lost. Understanding the limitations of mind and body as well as the limitlessness of the consciousness, the athlete should strive to reach the goal. Usefulness of asanas in sporting events Events that involve one-sided usage of the spine, either forward or sideways, or a combination of the two, in a static or dynamic manner, are hockey, polo, golf, billiards, weightlifting, cycling, cricket, tennis, javelin, shot-put, discus and rowing. Asanas that are useful for athletes involved in these sports are shown in the illustrations—stretching the hamstrings (Hasta Padangusthasana, page 99) for hockey, lateral bends for polo, rotations for golf (Bharadwajasana on chair, page 99), lateral bends and rotations for billiards, back bends for cycling, rotations and lateral bends for cricket, and shoulder and arm movements for the others. Events that involve asymmetrical hand and cervical muscle usage, either in movement or in a static manner are archery, shooting, billiards, cricket, golf, basketball, polo, tennis and athletic throwing events. The asanas that are prescribed are illustrated. There are a variety of available movements and only pertinent ones are shown — holding the window bar, double rope backbend, Dog pose (page 98 and 100).

Events that involve the lower limbs in an asymmetrical manner are golf, running, jumping events, cricket, tennis, football, soccer, hockey, billiards and polo. For these, see illustrations of Upavishta Konasana, Supta Padangusthasana, Krounchasana (page 101). Events that involve over usage of the leg and foot in an asymmetrical manner are gymnastics, running and jumping events, tennis, hockey, squash, throwing events, cricket and football. For these see Virasana, Baddha Konasana and Padmasana (page 102).

The Artist and Yoga The word art, in the dictionary, means human skill as opposed to nature. An innate skill in performing any action is art. The ultimate goal of every art is to induce delight in the spirit of man and help him attain divinity. Art represents the inner need for expression. Each mind is different, so is art highly varied. Indian tradition recognizes 64 arts in all, covering all fields of life. Mastery in all of these is said to have been achieved only by sage Narada, the son of Brahma the Creator. According to Patanjali, art depends on direct perception, imagination, inference and knowledge. The artist has to be creative. Creativity is a state which is the source of all knowledge. Creativity is never stagnant. The moment stagnation occurs, creativity is lost. Patanjali says that ego, laziness, lethargy, dullness of mind, fickleness, illusion, depression, are all obstacles to art. Art requires a strong psyche. Skill in any kind of art can be achieved only by long periods of involvement in it. Lord Krishna says in the Bhagavad Gita that yoga is skill in action. The right state of mind is essential for any action, however simple it may be. If each action is carefully attended to, daily life becomes a state of art. According to Patanjali, when the mind is ripe and all states — conscious and subconscious — have become one, this is the state of samadhi. The exalted artist possesses this faculty which is the source of all creativity. Perfection results when a person is totally immersed in achieving something of unparalleled distinction. The process of achieving mastery and perfection in one’s avowed artistic sphere — whether it is music or painting or acting or dancing — takes a toll on the artist’s physical and mental health. To guard against this, yoga is invaluable. Yoga gives the guidelines for evolution of the body and mind through the sutras of Patanjali. Yoga requires perception, dexterity, imagination and practice. Art is similar. Yoga is also a scientific technique whose effects can be reproduced time and again. I have highlighted the inherent hazards in some of the better known forms of artistic practice. Some kinds of art require body movement, some need perfect stillness, others a combination of the two. For example, one may be a painter, an architect, a musician or a dancer. Several parts of the body are used by all of them and, due to years of repetitive action, the muscles and joints tire and postural problems arise. This is manifested as pain and inability to use the affected part as well as before.

Counter movements are essential to release strain. I have explained how asanas and pranayama are useful in alleviating a variety of conditions and in helping the artist to effectively achieve his or her inner goal.

Indian classical dance There are seven schools of classical dance in India — Bharatanatyam, Kathak, Kathakali, Odissi, Kuchipudi, Mohini attam and Manipuri. All of them are centuries old and are mainly religious in content. They use extensive body movements, especially of the feet. In a few styles, the movements are often high impact ones, while some like Manipuri is slow and sinuous. Many Bharatanatyam dancers are prone to chronic pain in the cervical and lumbar area. Injury to the ligaments of the knee and ankle are also common. Most of this is related to the forceful strike of the foot on the ground. Over the years, the muscles, cartilages and ligaments wear out. The incidence of pain is also directly related to the hours of dance practice. The cervical muscles are constantly arched and held at a particular level of tension. This prevents proper absorption of impact when the heels strike the ground. The same can be said for the dorsal and lumbar spinal muscles. In some dancers, severe wear and tear in the spine, though radiologically detected, can be paradoxically asymptomatic. The constant elevation of the arms produces contraction of the trapezius muscles, leading to pain. The inner arm and armpit muscles are also constantly contracted. The groin muscles are overused as they are kept at the same angle for many hours. This can produce altered gait, which the dancer might be unaware of as they are used to a particular posture and movement. Owing to the altered angle of the groin, the sacroiliac muscles suffer pain as they are constantly contracted. The hips are often used asymmetrically in dance, particularly in the tribhangi posture. Pain in the low back is a common feature. The knee suffers repeated usage at a particular angle. So do the ankles, and the inner arches of the foot. Without flexibility in the inner groin muscles, the knee cannot turn out in the ‘ara mandi’ position. The ligaments can be injured. The posterior leg muscles are also kept shortened, while the Achilles tendon is stretched. Often the tissues of the heel are the most affected, due to the high striking force. Even if the force is low, the constant strike over the years wears away the skin and subcutaneous tissue of the heel. The pad of fat on the heel wears out if the foot strike is forceful and the heel bone is irritated due to the impact. This leads to spur formation in the heels. Also, a majority of dancers suffer pain due to inflammation in the heels-plantar fascitis. The ‘ara mandi’ posture in Bharatanatyam involves constant external rotation of the knees and hips. This is unhealthy unless accompanied by counter movements. The addition of forceful foot strike in this position injures the knee. As the back is kept wrongly arched for balance, and is subjected to impact, frequent back muscle spasms are not uncommon in the dancer. The neck can suffer from the impact as well. It is essential for the dancer to loosen specific muscles of the body before learning the art. This can take several months, and till then no dance lessons should be introduced. Today, students do not attend

to preliminary loosening up exercises and hence, the high incidence of injury. Similar problems can be observed in the Mohini attam and Kuchipudi styles. Kathak originated in the temples of Rajasthan. In this style, the feet are used as ‘percussion instruments’. The emphasis is on the speed of the feet. The dancer has to end the body movement suddenly. The spinal muscles at all levels can get into sudden spasms with such usage. It is common to see dancers suffering from recurrent ‘catches’ in the spine. Over the years, the dancer suffers loss of the normal arch. In fact, all dancers who use their foot intensively tend to develop flat feet. Alternatively, the subcutaneous tissues are so worn out that their protective function of cushioning the weight of the body is ineffective. The feet suffer from frequent callosities. Kathakali of Kerala is essentially a dance drama. The body movements can be sharp, violent and expansive. Facial movements are so minutely controlled that expressions and movements on either side of the face differ. Hence sagging of facial muscles can be observed. The intense training, involving excruciating exercises and massages, can overstretch the joints and muscles. Manipuri is the style from Assam. Here the foot impact is mild and the dancer suffers less. The body movements are sinuous and slow. In all these forms of dance, the pace is continuous. It is difficult for the dancer to involve herself in expression and to be aware whether the right or left part of the body or the heel, the inner or outer part of the arms or wrist and so on, are used symmetrically or not. Nevertheless, the injuries caused by years of practice and performance need care. The moment the technique is modified, the pain regresses.

Ballet Ballet originated in Italy as theatrical dancing. It was refined into a classical form in the late nineteenth century. The basic movements consist of five different positions. The most common is with the feet turned out. In ballet, the intrinsic muscles of the foot are placed under great strain. The big toe can suffer stress fracture. The muscles of the foot and the calf are overused and hypertrophied in comparison to the rest of the body. No doubt, the dancer goes through a wide range of preparatory movements, but the concept of alignment and centering is not technically suited to the body. In the long run, there is excessive strain on the ligaments. The impact on the joints is less than in some forms of Indian dance, but the constant load on some parts is greater. Stress fractures in the feet are common in professional dancers, as is amenorrhea. The knee joint suffers excessive strain on the inner ligament as it is constantly rotated outward. The sciatic nerve is twisted along with the outward rotation of the thigh. Inner knee pain is common in many dancers. In extension movements of the spine, alignment to the groin muscles is neglected, promoting strain. The spine suffers hyperextension in many dance sequences, leading to chronic low back pain. Weight reduction and maintenance at a low level make for weak muscles and ligaments of the spine. The

ballet dancer always has an excessive arch of the lumbar spine — the so-called increase in lordosis.

Modern or American dance Modern dance began in the early years of this century in the United States. In this dance form, the central parts of the body suffer more than the periphery. The body is used more in the horizontal plane with twisting, tilting and bending movements. The strain on the feet is much less than in ballet as the joints are moved through different angles. Again, the concept of centering and alignment of body movements is incorrect.

Jazz dance The jazz style of dancing borrows from various styles. It requires stamina. Isolated movements of the pelvis, shoulder and hips are common. Such movements cause over flexible muscles and chronic pain due to fatigue. Care must be taken to prevent sprains. As the pelvis is constantly made shallow, the pelvic organs will suffer from want of fresh blood supply. The spinal muscles, being made convex, lose the normal concavity. This causes low back disorders. The jazz dancer also involved in ballet, tap and ethnic forms, faces problems according to the pattern of muscle usage. Tap dance In this unique American style, metal plates attached to the feet strike the hard surface in different ways, producing a variety of rhythms. The movements include a shuffle, brush, flap, heel drop, slap, stamp, step and stomp, and many other step patterns. The intrinsic muscles of the foot have to move very skillfully to create the various sounds. This involves constant contraction and relaxation of many muscles. The tendons and muscles on top of the foot suffer from cramps. The muscles of the foot require proper massage and relaxation to prevent fatigue. The other parts of the body do not suffer from impact. Ethnic dance Ethnic dance, one of the oldest forms of dance in the world, is of many varieties. Movements in some are similar to the ballet. The Indian dances (already described above) are also classified under this category. The Spanish type requires the same skill as in ballet. There are also the regional variations which have kicks, leaps and turns. The flamenco is thought to be Hindu in origin. It involves tricky steps at breakneck speed. Black dance can involve foot work, arm work, and use of the torso. Dance is an art. It is important that the dancer practices the art without suffering side effects. It is essential to understand that even in creative and aesthetic movements; the positions of the body are not always conducive to the health of the joints and muscles. Yoga, being a system of postures, is ideally suited to help dancers. Yoga can be done at any age and hence experienced dancers will also benefit. The movements in yoga align and soothe the tissues. A massaging action is imparted to the inflamed tissues which relieves pain.

Standing poses strengthen the ligaments of the hips, knees, ankles and feet. The steady state muscle action in these massage the cartilages and muscles, relieving chronic low back pain due to constant impact and faulty alignment. Props are valuable if the dancer is tired. Dog pose is particularly valuable for the lower back. Forward bends stretch the spine, relieving backaches in styles that involve a constant backward extension of the spine. Inverted poses (below) provide circulatory energy for prolonged periods of dancing.

Simple leg inversion drains de-oxygenated blood, refreshing the legs.

Back bends are valuable for providing aerobic stamina. The dancers do not get breathless. Seated asanas like Virasana, Supta Virasana and Padmasana are very useful to give relief to the cartilages of the knee. The semilunar cartilage of the knee suffers the most and, in Virasana, the femur is pulled away from this cartilage. The position of complete flexion relieves pain. Both Virasana and Supta Virasana should be practiced after every dance session. This keeps the entire lower limbs fresh by massaging the muscles. If the dancer is tired, practice of half Halasana, Setu Bandha Sarvangasana and Viparita Karani relieve fatigue. Inversions prevent cervical and shoulder problems. Easy fatigability is avoided and rest is given to the muscles of the lower limbs. Passive back bends before or after a dance session also provides energy. The pad of fat in the heel has to be protected by the use of rubber heel pads during practice sessions. This ensures that the fat pads last for many years. Dancers often tend to be underweight as they have to maintain optimum body weight for performances. This can interfere with proper nutrition and produce amenorrhea. As the body is not

used symmetrically, bone densities are higher in overused areas. Asanas teach right coordination and even usage. I have dealt with some major forms of dance and their inherent problems. Any movement done repetitively over many years, if dynamic in nature, can cause wear and tear. To prevent this, yoga is valuable. The body cells are rested. The nerves are soothed. Yoga is the only system where the concept of alignment and centering is medically precise. Practice of pranayama gives the necessary serenity to the mind of the dancer. It also gives the heart and lungs enough stamina. As yoga is a science of kinetics, it helps the dancer to understand the body in a more systematic and holistic manner.

Indian musical instruments Instrumental music in India is produced by a wide variety of devices. All of them, whether stringed or percussion or wind, as well as vocal music, result in some parts of the musician’s body being used more than the rest. Certain groups of muscles are overworked and either stretched or contracted both causing stiffness and pain in later years. Musicians have to be particularly attentive to such problems so that they can continue to derive and give pleasure from their artistic talents well into their mature years. Stringed instruments In all the different kinds of stringed instruments of Indian origin, different groups of muscles are overworked depending on the kind of instrument and the position of the body. For example, the person using a musical instrument in a vertical manner, like the tambura, has to keep the right hand elevated for many hours. This leads to contraction of the deltoid and biceps, and stretching of the triceps. The pectoral muscles of the right side are also contracted. Over the years, the player contracts pain in the right shoulder and pressure on the root of the cervical nerves on the right side. A similar problem can be seen with the sitar. If an instrument is used horizontally (veena), one has to bend forward to curl the hand to reach the frets. This not only affects the muscles of the hand and the shoulder, but also the spinal muscles as the body has to bend forward and to the side. This causes cervical and low back pain. With a violin, the instrument is pressed into the chest and the left hand curls over to reach the stem. The right wrist is flexed constantly, and the right armpit always contracted. Many violinists suffer from lack of dexterity in later years as the muscles have never been stretched. The skin on the tips of the fingers also becomes hardened and fine sensitivity is lost. But this does not affect daily functioning. The santoor is one of the instruments where the player has to use both hands fairly evenly. Provided the player assumes an erect posture, problems may not arise. The armpit muscles on both sides remain contracted always. Awareness of body positions in relation to the instrument is essential for any musician, especially professionals, if future problems are to be avoided.

All standing poses are valuable for spinal muscles. Inverted poses train the cervical and shoulder muscles for symmetry. Sarvangasana is important to give relief to pain in the cervical and trapezius muscles. Back bends, with or without props, help maintain proper posture. As all the parts of the body are expanded in these poses, they are a boon for musicians. The chest is expanded to the maximum to stimulate healthy breathing. Associated hand movements prevent degeneration of the nerves and muscles in the upper arms. Asanas give relief to the musician by counter-positioning the body muscles. This prevents chronic contraction of muscles.

Supta Padangusthasana (hamstring stretch) improves blood circulation in cramped muscles.

The most important problem faced by such musicians is that of circulatory stagnation because the body is kept static most of the time. Exercise is essential to induce a dynamic quality to the circulation (above). It is essential to attend to the lower limbs as the usual seated posture prevents healthy blood flow into these areas. If the person has to stand for long hours, inversions followed by Supta Virasana give relief to the muscles of the legs. Practice of pranayama steadies the nerves and makes the mind calm, removing stage fright. The sensitivity of the tissues of the skin is enhanced, allowing better quality of fingering. Percussion instruments Some percussion instruments are played with the palms alone. In others, the tips of the fingers are used, while in yet others the player uses instruments for percussion. In the mridangam, for example, the musician uses the tips of the fingers and the base of the palm. The palm, being a tough area, is unlikely to get affected. The same cannot be said for the fingers. The skin on the tips of the fingers

becomes thickened over years of use. For the tabla, the musician uses the distal tips of the fingers which are the most sensitive parts. Fine tactile sensations are likely to be blunted. The posture used for playing must be correct. Usually the shoulders are hunched and the trapezius muscles contracted, leading to cervical pain. Some percussion instruments are hung around the neck and on the shoulders. This affects the alignment of the cervical vertebrae in the long run. Some instruments are hung on one shoulder, creating asymmetry of shoulder muscles. Percussionists are exposed to another occupational hazard — that of the high sound effects produced by their own instruments. Drummers of pop music and players of the South Indian instrument thavil (played on auspicious occasions), are particularly susceptible. Thorough research is needed to establish safety levels of sound for these instruments. Asanas recommended for the players of stringed instruments are useful for the percussionists too. It is essential to maintain the softness of the tissues of the skin on the palms and fingertips. Soaking the hands in warm water for a brief period every night and the use of glycerine or moisturising lotions are needed. As the senses are exposed to constant sound, Shanmukhi Mudra or forward bends, Halasana with the stool, Viparita Karani with the bandage on the eyes and face, are good. The inner ears are protected. Pranayama gives relief to the stressed nerves. The use of the bandage is essential. Abstinence from using the instrument will definitely lessen the stress on the auditory nerves. The person may well have got used to the level of sound and may not be aware of the strain on the mind and the nerves. Practice of pranayama keeps the person in contact with the inner and outer quietude, enabling the perception of the strain on the auditory nerves by the instruments. Wind instruments Exhalation is the force used to activate these instruments. An analogy is practicing pranayama using exhalations alone which can be detrimental to the lungs and heart. During inhalation, the output of blood from the left ventricle reduces slightly, and that of the right ventricle increases. The situation is the reverse on exhalation. The chambers of the heart thus change shape from moment to moment. Add to this a powerful wind instrument, and one can understand the strain on the system, especially for professional musicians. Some instruments, like the flute, do not require forcible lung action. It is a slow controlled exhalation with change in lip shape. The strain on the cheek muscles and their shape varies with the type of instrument. In some, like the trumpet, the cheeks are puffed out and in others, like the clarinet, the muscles are hollowed out. The heavier instruments like the nadaswaram require powerful lungs for healthy sound. In the long run, the cardiac chambers are overstrained. The lungs become weak due to the constant compression of the intercostal muscles. Over usage of the lungs could lead to occupational emphysema. The facial muscles sag with habitual playing of wind instruments of a heavy nature. It is essential that the player gives rest to the lungs and heart by the practice of asana and pranayama.

Asanas stretch the lungs open and give rest to the intercostal muscles. An easy method is to use the props to ensure immediate relief. Viparita Dandasana done on the rack is excellent for cardiorespiratory fitness. All asanas are useful. Specific attention has to be paid to the limbs and posture of the entire body, with asanas directed to the group of muscles and joints that are overworked. Pranayama provides relief to the lungs of the musician as the deep inhalation relieves strain on the intercostal nerves. Supine pranayama on bolsters is important, especially for the nadaswaram artist. For those exposed to high sound levels, the use of the bandage on the facial muscles and ears provides relief to the organs of perception. The mind relaxes and stress is removed. It is a generally held view that music can do no harm to the body, but it must be remembered that the ear is exposed to constant auditory stimulation. Just as the mind should be kept quiet for a certain period every day, the human body also needs rest. Specific mention must be made here of vocalists who use the body as a wind instrument in the art of singing, by regulating the inflow of air through the vocal cords. Many vocalists suffer from vocal nodules, due to excessive usage of the vocal cords, especially if the cords are not very strong. Once vocal nodules are diagnosed, rest to the voice is essential, varying from a few weeks to several months. Most singers are unable, or unwilling, to cooperate and hence continue to suffer the disability. Practice of asanas, particularly Head stand, Shoulder stand of the niralamba variety (page 122), and half Halasana on the stool are invaluable in providing relief. Halasana is an excellent asana that gives relief to sore throats and inflamed vocal chords. Proper timing in these poses is essential for good relief. If a vocalist practices such asanas as soon as training is begun, such problems do not occur. Pranayama, particularly ujjayi, massages the cords and improves the blood supply. It also strengthens the cords in singers who have lost the resilience of pitch and suffer muscle fatigue. It is no exaggeration to state that if singers practice pranayama from a young age, the voice remains healthy. Sitali pranayama soothes the throat and reduces the heat generated in the pharyngeal lining. Proper daily care of the throat is essential. It is not rational to avoid chilled drinks and consume warm fluids only, as many do. The cells of the body need to be stimulated and contracted. Hence, both are essential in moderation. The addition of turmeric and ground black pepper with saffron to a glass of warm milk every day preserves the vascularity of the mucus lining of the throat and prevents soreness of voice. It also keeps the voice soft and melodious. Drugs or surgery have a limited role in treating vocal nodules unless the nodules are of considerable size and cause extreme discomfort. Natural methods are healthier and conducive to recovery. Western musical instruments The body is not strained much while using autophonic instruments like cymbals, rattles and bells. For aerophonic instruments, the mouth is used in different positions. The tip of the instrument may be entirely in the mouth or merely in external contact. The muscles of the tongue are thus used differently. The strain on the lungs depends on the type of

organ used. For example, they are strained less in using the mouth organ than the bassoon. Consider a clarinet — the instrument is light and does not disturb the muscles of the hands and the shoulders. But the cheek muscles are predominantly overused, even though the lungs and heart are not strained at all. This is in direct contrast to the nadaswaram of India where the lungs and heart are overstrained to the point of affecting the chamber size of the heart and creating overdistension of the lungs. With regard to membranophonic instruments, heavy instruments like the drum, hung on the body can create neck and shoulder problems.

Niralamba Sarvangasana massages and soothes the vocal chords. The wall support is essential.

Chordophonic instruments like the guitar use the shoulder and neck muscles asymmetrically when they are played. The forearms are used differently, and as the right arm has to pluck the strings, the right side of the neck and shoulder suffer constriction. The other arm having to curve around the fret, the forearm muscles are constantly contracted. The fingers of one side develop dexterity while the other lacks it. Yogic asanas are the ideal means by which players of such musical instruments can counteract the over usage of different parts of the body and provide relaxation to such muscles. The guidelines are the same as mentioned for the Indian instruments. All parts of the body must be attended to. The spine and the hands are taken care of by standing poses and hand work on the wall ropes. The throat, neck, and facial muscles are attended to by the inverted asanas and back bends. Shanmukhi mudra with the bandage relieves strain on the facial muscles and the senses. Pranayama protects the heart and lungs

from the constant fluctuations in the respiratory rhythm caused by the wind instruments. It is essential that musicians understand that even their occupation has inherent problems. Yoga has to be intelligently used to help them continue their work and maintain quality of performance throughout their life. Regular practice of asanas and pranayama preserves physiological functions well into old age.

Painting and sculpting Painters and sculptors are artists who have to maintain fixed positions for many hours. The angles are such that certain muscles and joints are excessively strained. Over the years, degenerative changes set in. The sites usually affected are the neck and thoracic spine, the shoulders and hands. The lower back is also prone to constant flexion and the inter-vertebral discs are constantly compressed, resulting in chronic low back pain. A painter’s hands are constantly abducted (movement away from the midline of the body), stressing the deltoids and trapezius muscles. The neck is turned towards the work spot and this creates asymmetry of movement. Chronic contraction leads to pain. In ambi-dexterous persons the problem is less. The painter should practice certain specific asanas to relieve muscle spasm and pain. Standing poses are useful. The most useful movements are Head and Shoulder stand, the latter with a belt over the arms (above right). This releases tension from the neck and the trapezius muscles. The person will immediately feel a sensation of relief, superior to that given by any analgesic (though for acute pain medication is mandatory). Asanas like hand and elbow stand, dog pose, forward bends are all additionally helpful to release tight muscles in the neck and shoulder. For the person who cannot cope with these, simpler exercises like strapping the arms behind the back with a belt (refer chapter on osteoarthritis), holding the window grills, are useful. The use of traction with the rope on the shoulders (page 124) is very useful to relieve pain in the neck and shoulder.

Sarvangasana with belt over arms.

The sculptor suffers similar pains. All the asanas mentioned above are useful for pain relief and correction of alignment. Periods of rest from constant activity are most helpful if the artist can manage it.

The celluloid world Nowhere are artists so much under strain as in the film industry — not only the artists on the screen, but those behind it too! Irregular eating and sleeping hours, constant exposure to artificial light, damage to the skin due to repeated use of cosmetics, emotional involvement in the roles, worries about success and failure in their career, all these are some of the occupational hazards in this field. And, inevitably, they lead to stress related disorders of the body and mind. The cardiovascular system is under constant sympathetic stress. The emotional strain in having to get

fully involved with the characters played affects the circulatory system easily. Hypertension is often the earliest disorder that a cine artist suffers from. Abnormal and exhausting working hours on the one hand, and excessive socializing with indulgence in smoking and drinking on the other, ravages the system. Unhealthy diet damages the lining of the arterial wall, with dyslipidemia being a risk factor. The rhythm of the artist’s biological clock is under strain. Hence, over the years, the blood pressure often gets reset at higher levels. To combat this situation, practice of yoga is far more effective than drugs. All asanas are useful and props are necessary. If the artist is exhausted and is resting on the sets, props set up in an ante-room can provide for practice of passive asanas like Viparita Karani or Viparita Dandasana. This provides instant recuperation. Forward bends provide relief from the excess sympathetic drive and are hence cardio-protective. Every effort must be made by the artist to practice supine pranayama, to release sympathetic stress. The daily schedule must begin with the practice of yoga. If most of the filming is outdoors, the lungs secure fresh air (else stale air). In addition, active and passive smoking damages the lungs. If time does not permit regular exercise schedules, respiratory de-conditioning is bound to occur. Back bends with props can be done between shots if the artist is unable to find time to learn the actual asanas. This is a quick, effective method. Sometimes artists sweat out in a health gymnasium for hours. Instead, yoga provides pulmonary conditioning and, in addition, stress relief in a therapeutic manner. Irregular work hours affect the sensitivity of the complex endocrine link with the digestive system. Peptic ulcers and hyperacidity result. Indigestion due to eating unhealthy food at wrong hours elevates blood pressure. Apart from peptic ulcers, diabetes mellitus is the most common disorder, owing to poor eating habits, alcohol, smoking and mental stress. Due to excessive indulgence in rich food, lipid levels increase predisposing the person to arterial blockages. The health of the digestive system can be ensured by the relevant asanas (see section on anatomy and physiology of the digestive system). Irregular sleeping and waking hours disturbs the bio-rhythm. A host of malfunctions can arise on account of this — high blood pressure, diabetes, insomnia, breakdown of the immune status with easy susceptibility to infections. The constant exposure to high levels of noise and powerful lighting can affect the delicate functioning of the endocrine system. Practice of Viparita Karani is highly beneficial to remove the stress on the glandular system, as is Shanmukhi Mudra. Other asanas include head stand on the ropes, shoulder stand on the chair, half Halasana, and forward bends with support. I have recommended the use of props, as recuperation is faster when one is exhausted. At other times the artist should practise without props.

Use of traction with the rope on the shoulders.

The nervous system is most affected. The need to excel, fear of competition, personal jealousies and ego problems, emotional attachments that often turn sour, fluctuations in one’s career, are some of the better known reasons why many film stars suffer nervous breakdowns. Addiction to tranquillizers, use of narcotics, depression and suicidal tendencies — such situations are far too common. Physiologically for reasons mentioned earlier, exhaustion, fatigue and lassitude are common. The constant exposure to high intensity lighting weakens the eyes. Early signs are seen in the area of the eyelids, which sag and become wrinkled. The cine artist is prone to all the disorders of the nervous system that the executive suffers — both have stressful lifestyles. The psychological aspects of the medical problems are of more concern than the physiological. All asanas done with the bandage on the face relieve tension. Pranayama stabilizes the mind of the artist. This helps the artists evaluate matters in their true perspective. As the organs of perception and

action are used to the maximum, soothing poses like forward bends, head stand on the ropes, half Halasana, may be useful. There are some health considerations that are common to all artists, apart from the occupational hazards their particular vocation exposes them to. The heart and lungs If the artist has to remain still for many hours, there is very little opportunity for the heart and circulation to be stimulated. The net result is a stagnant circulation with a greater tendency to atherosclerotic plaque formation. It is essential to stimulate the haemodynamics by some form of regular exercise. Yoga is ideally suited. Standing poses improve circulation in the legs. Inverted asanas optimize blood flow to the brain. The asanas that stretch the hamstrings are valuable for improving blood circulation in the legs. Back bends optimize coronary and pulmonary circulation. These asanas invigorate the cardio-respiratory system that has been stagnant for many hours. If time does not permit regular practice, props can be used. The digestive system Asanas are essential to stimulate healthy flow of digestive juices. Heat is generated by exercising and this maintains the health of the organs in the long run. Problems of impaired excretion do not occur. Absorption is better. A frugal diet is essential if the occupation is sedentary. Overeating, with no exercise, brings in its wake obesity, blood pressure and diabetes. All asanas are to be practiced. The endocrine system A healthy system requires periodic stimulation to remain intact over the years. If the sedentary artist does not ensure a schedule of exercises, the body will age faster. Even a few asanas are enough to maintain healthy functioning. Inverted poses like head and shoulder stand, dog pose and Uttanasana on the stool are sufficient. A few back bends are essential. Urdhva Mukha Svanasana, Ustrasana and Viparita Dandasana on the chair will serve the needs of the artist. The nervous system Forward bends and passive inverted poses with the bandage are essential to prevent mental exhaustion in the artist. Apart from this, pranayama done supine, or erect with the bandage, gives immense relaxation to the mind and nerves of the face. As the senses form one of the key elements of artistic performance and appreciation, Shanmukhi Mudra is highly beneficial to the artist, especially to persons who are exposed to high sound levels that can harm the auditory nerves. The locomotor system Apart from dancers, most artists suffer the effects of physical inactivity. As the body is not moved too

much, the muscles and joints (apart from those used, which do not anyway possess too great a range of movement), become stiff and inflexible. Hence low back disorders, cervical problems, and wasting of muscles in old age, which is different from that of the normal person, occur. Standing poses are invaluable. The back bend with the ropes on the wall are helpful to promote flexibility in the backward direction. These keep the spine in excellent condition. The emphasis on particular asanas varies according to the nature of the art. The bones are subjected to the effects of prolonged immobility, affecting a healthy transition into the geriatric age. In physically active persons, the incidence of fractures in old age is lower. Hence, standing poses which give a calculated load on the bones of the spine and legs serves this purpose. Though a few standing poses may suffice, specific asanas will be needed by certain artists. For example, the musician who performs in a standing position needs to rest the legs, in contrast to one who performs in a seated position whose muscles need to be stretched. Knee and hip joint problems are common in artists who need to be static for many hours. Depending on the type of position, the right or left side is affected. The groin can suffer the effects of prolonged immobilization. Baddha Konasana and Upavishta Konasana help improve circulation in these areas. As in sports, the majority of artistic activities involve usage of the body asymmetrically. Yoga is the only art that is totally symmetric in its practice. If the artist understands the symmetry of yoga, the asymmetry of artistic vocations will be understood. Many artists resort to painkillers and other remedies to cure physical problems before they turn to yoga. By this time, the asymmetry in the involved part of the body is of a severe nature. Many resort to walking as a form of exercise. This is good if there is no other regular exercise. Flexibility programs are, however, more important. Walking does give the opportunity to take a break from routine activity, to stretch one’s legs and refresh the mind. But it must not be seen as a substitute for yoga. Walking and yoga may be done on alternate days. Yoga is to be practiced not only for the present, but for the future. The artist needs to be healthy even at a ripe old age to be able to continue with the art. For this, it is essentially the mind and the locomotor system that need to be maintained in perfect order. Yoga is the only method that will provide consistent beneficial results as a preventive system of medicine. Patanjali and the artist Artists are said to be more sensitive than others to everything around them. It is equally important to be sensitive to their bodies. In practicing yoga, the artist learns the value of the body and mind as the source of artistic movements. In learning asanas and pranayama, the mind has to skillfully guide the different parts of the body to execute the positions. Yoga is the only holistic art that not only teaches the person to reach the core of being by penetrating the mental sheaths, but also provides ethical guidelines for the betterment of the body which is the vehicle of the soul. Practice of the eight steps of yoga outlined by Patanjali results in a more complete evolution of the individual. By the practice of yoga the artist learns clarity in presentation, honesty in practice and

subtlety of art. Every artist is imbued with the quality of tapas. It has to be further refined for its expression to reach sublime heights. Inner inspiration, which is apparently sourceless, is what makes for a successful artist in any field. None can account for this, unless the mind turns inwards and searches for the soul. Then, the higher realms of existence are realized. Ishwarapranidhana teaches the artist humility, and helps to dissolve the difference between the subject and object. In this state of mind the artists excel, as they are totally identified with the object of work. The practice of dharana and dhyana, culminating in samadhi, elevates the artist to the highest level of existence. Physiologically, this means the total functioning of all parts of the mind and brain. This increase in capacity leads to awakening of many latent faculties which are intuitive in nature. Intuition means direct perception, which is a boundless state. The artist functions best in such a state. The aim of art is elevation of man’s spirit. The aim of yoga is to transcend the spirit and achieve the timeless state of bliss. Mr. BKS Iyengar has beautifully summed up the value of yoga entwined with art thus: “Yoga is the rhythm of the body, the melody of the mind, the harmony of the soul, creating the symphony of life.” Therefore, yoga is a basic art and the parent of all arts.

Women and Yoga A woman has as exacting and taxing a job as any executive. She often combines in herself the roles of not only a wife and a mother but those of a cook, a chauffeur, a maid and a hostess. She is the quintessential manager, running the house efficiently and looking after the varied needs of her family. She provides moral support to her husband and children, and turns into a listening post and sounding board when they discuss their failures and successes with her. She is the one, too, who gives help and comfort to the older generation in the family. She is responsible for the family’s health and wellbeing. She has to inculcate healthy habits in them, see that their diet is good, that they exercise and do not fall ill. In the joint family set-up that still exists in many Asian countries, the housework is shared as also the expenses. Moral and physical support is always available in times of ill health or other problems. Yet a homemaker faces stresses and strain. When she is young, she is expected to do most of the work; and, when she is older, she has to shoulder greater responsibilities. Very often, she is unable to fulfill all her potential. Today’s nuclear families present a different role for the homemaker. She has more independence, more clout, but she has more work and worries, too. If she has a career, the stresses are definitely greater. Unfortunately, with divorce rates going up steadily (even in India), many women are also single parents and have to be both mother and father to the children. Sadly, her significant contribution is often not appreciated enough. The various pressures and pulls on her are not understood. The woman who makes a home is thought to have a cushy job, without the burdens of office or school. She is expected to be around all the time, without considering her own personal needs. Things have changed owing to higher education for girls and the difficult economic front. Women are more ‘liberated’. More and more of them, particularly in urban areas, are working and contributing to the family’s finances. With all this, it is not surprising that a woman has as much stress in her life as anyone else. She has to be healthy in body and mind so that her family can keep well. She has to set the example of glowing health. To do so, she has to be aware of all that can go wrong with her, physically and mentally.

Medical problems of women There are two prerequisites to a woman attaining physical and mental health. The first is personal time allocation. She should expand her interests, in whatever field they may lie. A career woman must unwind from the pressures of her work in activities other than routine housework. Also, a balance

between home and work is needed. If there is understanding, cooperation and companionship in the family, the feelings of frustration and guilt that lead to a whole host of medical problems will not occur. She will achieve the equanimity of mind that is essential for the well-being of the entire family. Exercise is the second imperative for her to achieve good health. It might be argued that a woman is active from morning to night, but mere physical activity is not exercise. Exercise means performance. It means that the body and mind are put to a calculated stress and strain by certain movements, resulting in profound physiological changes. The physical activity of a housewife, for example, does not utilize her body to its fullest capacity. Gadgets, which save her time and energy, prevent healthy muscle usage. Many housewives suffer orthopedic problems due to neglect of the body. On examining such patients, I find that the muscles are stiff, the body weak, and even naturally simple tasks involving bending forward create back ailments. Decades ago, the very lifestyle in some countries provided for flexibility. In India, even today, the habit of sitting on the floor for eating persists in many households (though this has reduced greatly). By sitting on the floor, the back is kept flexible, and the pelvic muscles remain supple. Biologically, women age faster than men, and therefore they should preserve their health by adopting appropriate measures. Yoga is ideal. As has been emphasized in the earlier chapters, asanas and pranayama are different from other forms of exercise in that they do not tire the practitioner and deplete energy levels easily. They relax and rejuvenate the entire system. Asanas correct many disorders that women are prone to. Let us discuss these in detail. The heart and the circulatory system Estrogen is cardio-protective and after menopause, the risk of myocardial infarction is almost equal for both women and men. Proper diet and exercise can prevent this. An unhealthy diet leads to blockage of the arteries. Lack of proper exercise prevents toning of the heart muscle. It also promotes hardening of the arteries and, if it affects the coronaries, it results in a heart attack. This is more common in career women due to the high levels of stress. High blood pressure is another disorder which needs careful treatment. The condition of the facial tissues is an important index to a healthy circulatory status. Many women age prematurely and this is easily observable on the face. The circulatory system becomes sluggish due to the low level of physical activity. Excessive duration of standing causes varicose veins. Many housewives suffer swollen feet at the end of the day due to poor return of body fluids to the heart. The circulatory problem is also aggravated during the menstrual cycle when some women complain of leaden feet and a heavy feeling throughout the body. This is due to fluid retention owing to hormonal changes. Back bends are particularly important for preventing and relieving coronary problems (even for the menopausal woman). Forward bends with support relieve elevated blood pressure. Inversions are very important to enhance and maintain a healthy circulatory status. They preserve the integrity of the facial tissues and relieve stagnation of fluid in the legs. They also prevent generalized water retention during the menstrual cycle, by regularizing the hypothalamic-pituitary axis which regulates water balance in the body. Inversions give rest to the heart from the strain of gravity. Use of Supta Virasana

after inversions greatly relieves the discomfort of swollen feet and varicose veins. All standing asanas are useful to increase circulation in the heart and the body. The use of props makes the pose easy to achieve (see next page). Supta Virasana, Setu Bandha Sarvangasana, Viparita Dandasana, and Urdhva Dhanurasana are some of the necessary postures.

Sarvangasana on a chair is easy to learn and has quick benefits.

Pranayama enhances cardiovascular fitness. Practice of kumbhaka energizes the heart. This improves effort tolerance without actually requiring the body to run for a mile. Moreover, venous return is healthier. The facial tissues are kept soft and supple when the bandage is used during pranayama practice. Except bastrika, all types may be practiced during the menstrual cycle. For essential hypertension, Viloma pranayama (type one) is good, but it has to be done under guidance. Blood pressure is controlled better in supine pranayama. Low blood pressure is also corrected by pranayama practice. The lungs The lungs need constant exercise to remain healthy. Young women are often unable to climb a flight of stairs without getting breathless. The lungs are the conduit for the drawn in energy (oxygen); distribution of this essential nutrient to the cells suffers if the vital capacity of the lung is not well

preserved. Problems like asthma and bronchitis need continuous care, best achieved by regular exercise. Many asanas can be practiced to prevent these conditions, especially back bends on the props (or without, if the individual’s condition permits). It is better that a woman restricts the use of props, and exercises to the maximum to ensure healthier respiratory toning. She requires plenty of energy which is best achieved if the lungs are functioning well. Though all asanas are valuable, back bends are particularly useful. It may not be necessary to practice complicated back bends. Asanas like Urdhva Mukha Svanasana, Ustrasana, and Urdhva Dhanurasana (on the prop if needed) will serve well. Pranayama on the pillows, practiced for fifteen minutes daily, will give fresh oxygen and inner vitality at the cellular level, to relieve chronic lung disorders. The gastrointestinal tract Poor appetite and unsatisfactory digestion are common complaints of homemakers. The latter can exist without the former. Due to lack of exercise, there is poor stimulation of acid flow in the stomach. A baseline level of hunger nevertheless makes the person eat. As the system is sluggish, absorption and digestion are dull. The liver and gall bladder work poorly. Proper utilization of sugar is prevented if there is little demand. Sometimes, even healthy women are found to be anemic. Moderate exercise stimulates hunger. Neuro-endocrine mechanisms are regularized. Standing poses are valuable. Forward bends stimulate appetite and asanas like Yoga Mudra and Pawanamukta Virasana will help. Proper timing is essential in these postures to stimulate the flow of gastric juices. They are contraindicated for the person who suffers from hyperacidity. Highly emotional women suffer from the problem of ulcers or hyperacidity. Being a career woman adds to the stress. For such patients, back bends provide relief. Practice of Supta Virasana and Purvottanasana on the bed after food relieves dyspepsia. The heaviness in the digestive organs, and the bloating and belching many women suffer after eating food, is controlled by such asanas. If there is an ulcer, the improved blood supply and reduction of acid flow in the stomach help the pathological area to heal, though medicines may be necessary. All asanas except forward bends can be practiced. Asanas promote burning up of excess sugar in the body if practice is intense. Constipation is usually due to low fiber content and absence of exercise. In addition many (particularly multiparous) women complain of excessive flatulence, with distension and consequent discomfort. This can be eliminated by correction of the diet (removal or reduction of materials which favor excess build-up of wind, like peas and sprouted pulses). Exercise also helps massage the intestines and expel the wind from the system. Twisting asanas are invaluable to eliminate excess wind and improve digestion due to the intra-abdominal massage of the liver and gall bladder. The modified versions of Bharadwajasana on the chair and standing Marichyasana near the wall will be adequate when the usual routine of twisting poses cannot be mastered. Women who have undergone two or more childbirths tend to have a protuberant abdomen, if they have not taken care to make the muscles of the abdominal wall firm. There is a predisposition to bloating of the abdomen with the slightest intake of food, with failure of elimination of wind (naturally formed in the intestinal tract). The sagging abdominal wall fails to maintain proper intra-abdominal pressure (which retains the organs in place).

A healthy muscle tone maintains optimum contraction of the muscle layer, preventing accumulation of wind in the intestinal tract. Asanas like Navasana and Ardha Navasana are useful to contract the abdominal wall. The pressure of firm abdominal muscles on the organs is also necessary for proper blood circulation and digestion. A flabby abdomen causes frequent digestive problems. Many women gain weight after each delivery, resulting in problems like blood pressure, diabetes, poor digestion and hernia. The treatment of blood pressure and diabetes are dealt with later in the book. Several asanas are useful to prevent hernia. In select cases they render surgery unnecessary. Props are valuable to learn the asanas faster and more accurately. The accuracy helps narrow certain apertures which have become patulous, allowing a hernia. Pranayama relieves the sluggish function of the digestive organs. Gastric stimulation is provided. The circulation in the pancreas, liver and gall bladder is toned up. Due to massage of the intra-abdominal organs, constipation is relieved. A healthy appetite is maintained. Dyspepsia is prevented by the use of bandhas during pranayama practice, e.g., Uddiyana Bandha. The glandular system The glandular system needs to be healthily stimulated for efficient functioning. A woman needs daily exercise to ensure that her glands serve her well. It is particularly important to tone up the delicate neuro-endocrine system to get through menopausal changes easily. Thyroid inflammation is common in women. It can begin with an insignificant bout of fever and severe pain in the region of the thyroid. The woman slowly slips into an altered state of metabolism with loss of appetite, weight gain, and alteration in the menstrual cycle. Biochemical tests reveal hypothyroidism. She has to undergo hormonal replacement therapy for many years, perhaps even throughout her life. However, this is not harmful. Regular practice of Sarvangasana and Halasana massages the cells of the thyroid, improves its blood supply, soaks the area with immune cells and could prevent malfunction due to the pressure exerted (though studies are needed to ratify this). The last word on thyroid cell malfunction is yet to be said. Sometimes cells go haywire and start attacking other cells of the body. To a certain extent, regular practice of yoga maintains the intelligence of cells in the right manner, due to a conscious control exerted over the organ during asana practice. Such order is present only if the nerves and the chemicals interacting with them are in perfect quietude. Inverted poses like Head stand, Sarvangasana, Halasana, forward bends like Paschimottanasana, back bends like Urdhva Dhanurasana and Viparita Dandasana, all regulate and optimize the blood supply to the endocrine glands. They also maintain healthy nervous control. In the middle and older age groups, higher energy levels are maintained by regular practice of asanas. Lack of sufficient physical activity can cause diabetes. The increased consumption of junk food causes over ingestion of sugar. The pancreas struggles and the blood sugar level rises. Some women are overweight and have never exercised throughout their life. Such women have poor control over the disease state. The practice of asanas must be of high intensity to promote better release of insulin

from the pancreas and improve peripheral utilization of excess sugar. Regularity of practice is essential. Decreased adrenal activity, a common age-related endocrine dysfunction, is responsible for lack of energy. If the adrenal gland is well stimulated by asanas, such changes will not occur. Standing poses invigorate the glands. Inversions “recharge” the adrenals. Forward bends soothe the overdrive. Half Halasana relieves the overdrive (recuperation from fatigue). Energy levels depend principally on healthy endocrine and nervous functions. Yoga interacts in these areas by stabilizing the inner vital life force in our body. Pranayama connects the glandular to the nervous system and maintains sensitive functioning. Prana is all forms of energy, regulating its movement harnesses energy from the endocrine system. There is a certain vital force in the nervous and glandular systems which are toned up by pranayama. When glandular failure occurs and replacement therapy is given, the patient may not feel energetic till pranayama is practiced (as the autonomous nervous system is one of the areas through which pranayama induces its effects).

Overweight — a problem for many women I often find women complaining about their weight which, according to them, is always a ‘recent’ phenomenon. This is so insidious a process that they fail to notice the gain. It is not difficult to shed excess weight if tremendous motivation is present. This inner force is often at low ebb as one grows older. Weight gain is possible even if a normal diet is observed (the body converts whatever is eaten into fat). In such cases, exercise is very useful. Overweight promotes premature degeneration of the joints, particularly the weight-bearing ones like the hips, the ankles and the knees. Degenerative changes occur in the spine. The skin of the overweight person becomes pitted and knotty due to the fat aggregating into lumps. The person who practices yoga habitually finds that she cannot eat heavily as the body rejects it. If the woman is already obese, it is necessary to use high intensity workouts like weight training and aerobics, and then switch over to yoga in order to prevent further weight gain. Yoga cannot make an obese person slim as it is not geared to achieve that. However, the asanas are designed to ‘scrape’ and squeeze the underlying tissues making it difficult for fat cells to accumulate. In some, there might be an initial gain in weight due to better absorption than before. Once the ideal body weight is reached, the practice of asanas maintains the weight at this optimum level. The inner lightness experienced in the stomach due to exercise prevents overeating. Indulgence affects the practice of yoga next day. An unhealthy heaviness in the system is felt at once. Habits of smoking and alcohol consumption are also stopped automatically, preventing disturbance of fat metabolism. In controlling weight, strenuous asanas like back bends are more useful than the milder standing poses and inversions (genes play a great role in weight gain or loss). The practice of Viparita Chakrasana is very invigorating and has effects similar to aerobic exercises, but here the mind is in deeper relation to the body. Hence, the cells are not irritated as in the case of jogging and aerobics; yet, they are

vigorously stimulated. Twisting asanas are useful to prevent fat accumulation around the waist and hips. With a high intensity weight loss program 1-2 years are required for optimum weight loss (variability is the rule here). The idea of ‘instant’ weight loss is wrong. A person loses weight very fast during an illness, as with chronic malaria, for instance. Hence, even this should be considered an indirect blessing to the overweight person. The nervous system It is essential, as a woman grows older, that the circulation in the brain and the fine regulatory mechanisms that serve balance and blood pressure, thinking and other intellectual processes, remain in perfect order. The most common disorder that affects the brain is a reduction in blood supply resulting in a stroke. The most widespread cause of a stroke is poor blood flow. Thickening of arteries adds to the problem. Regular exercise retards these degenerative changes. Regulatory mechanisms of the nervous system are toned up by stimulative exercises. The practice of asanas has a psychosomatic effect. In some postures, the ‘inner toughness’ of a person is challenged. In others, the capacity to remain passive in times of physical and mental stress is put to the test. In many others, the skill of the woman and her perseverance are challenged. All these help to reflect the personality of the woman and her responses to events in everyday life. The willingness to struggle to achieve an intricate asana in spite of pain is an indication that she can bear mental and physical challenges (to a point). The nervous system of a female may not (for hormonal reasons) be as strong as that of a male. Exercise gives her the opportunity to strengthen it. The inner strength in a body, which is mainly nervine, determines the longevity of the body and its resistance to ill health. Yoga brings her body to excellence in health. Standing poses develop skilful neuromuscular coordination of the peripheral parts of the body. Every nerve in the body is fine-tuned. Inversions prevent reduction in blood supply to the brain. Ischemic strokes are avoided. Neuronal degeneration is prevented. Hence, senile dementia, which is a condition where the patient suffers poor memory, loss of coordination, and degeneration of neuro muscular control, does not occur. Inversions also energize the entire system. Passive inversion on the ropes can be use used for those who cannot practice in the normal way. Dog pose and standing inversion are all helpful to maintain nervine health. Alertness, wish is a quality of the brain cells, is improved by the practic of inversions. The nervour system could be drain of energy during menstruation due to stain on the sympathetic nerves. Headache is a common complaint at this time. Practice of forward bends relieves this overdrive of the nerves and gives relief from both headache and exhaustion. Headaches occur if the mind and nerves are weak. It is a chemical depletion which produces the pain. Excessive stress is the cause. Migraine is a disorder of chemical imbalance and emotions aggravate it. In cases when the pain is more factual, (without psychosomatic overlay), relief through yoga is more perceivable. Forward bends done with the bandage on the face relieve migraine headaches, but modifications are needed to suit individuals.

Asanas that are useful to give energy at times of exhaustion can also be done with props — for example, Viparita Karani on bolsters against the wall, Adho Mukha Svanasana on the ropes, Head stand on with ropes, Shoulder stand on the chair, and half Halasana on the stool. The professional woman who also has to cope with housework will greatly benefit from half Halasana done at the end of a long day, followed by Supta Virasana on pillows. Supta Virasana relaxes the strained nerves of the legs. Shanmukhi mudra done with the hands, or the use of bandages on the eyes and face, relieves exhaustion of the mind and the person feels as though she has woken up from sleep. Refreshment is quick and without side effects. The quality of sleep improves. Back bends and balancing poses provide vital energy which other poses cannot. Around middle age, our energy levels start fluctuating. The vigor of youth begins to decrease. This change is balanced by regular exercise. The powerful inner drive of our system is both mental and physiological. Asanas help in both these areas. The insomnia issue An increasing number of women today complain of insomnia. In my clinical practice, I have noticed that the majority of them are career women with the added responsibility of home-making without much help. Unable to bear the stress and strain of their dual role, they lose sleep over the problems they have to solve. In this state, they turn desperately to some method that will ensure good sleep. The intake of tranquilizers begins. The question is often asked whether yoga can cure insomnia. Asanas and pranayama soothe the system and ensure a healthy pattern of sleep but, unless a basic change is made in the attitude towards life and its challenges, there can be no permanent solution. The physiological effects of insomnia on the body, namely, low or high blood pressure, and exhaustion due to glandular and nervous strain, can be tackled by asanas and pranayama. It must be however be borne in mind that the psyche is the sole cause of all such problems. Patanjali says that even the most advanced yogi may fall from the pinnacle of tranquility if he is not careful in keeping his mind under control. We can then imagine the plight of the common person. The vicious circle of worry over loss of sleep further weakens the nervous system. The continual use of tranquillizers induces dependence on them. The discontinuance of drugs provokes withdrawal symptoms. This produces greater worry, and the cycle never ends. A few guidelines listed below will help the insomniac improve the quality of her sleep: 1. discipline of habitually performed exercise 2. as far as possible set matters in order to avoid worrying later on 3. retiring around 9-9:30 p.m. and arising around 5-5:30 a.m. 4. avoiding irritants like caffeine and alcohol

5. avoiding the use of tranquillizers 6. not watching mentally stimulative shows on television before bed time 7. unless really tired, not napping in the afternoon 8. ensuring the maximum possible silence around at bedtime; 9. allocating some time in her daily life for a short period of silence and relaxation and, if possible, meditation 10. last, but not the least, getting her family to help maintain her routine. Sleep disturbances can be adequately prevented by the habit of regular exercise. The basic factor of control is neuro-hormonal and exercise changes the pattern to a healthy profile. Passive inversions and forward bends with half Halasana, followed by Setu Bandha Sarvangasana and Viparita Karani, are valuable. Pranayama is the most useful, as the very consciousness is completely stilled and the person is brought in contact with the core of her being. According to yoga, pranayama stabilizes the vital sheath (for vital sheaths, refer section on nervous system). If there is any disturbance in the vital sheath, disorders in the form of restlessness, insomnia, recurrent infections, and fatigue occur. Sleep patterns are better in persons who exercise regularly and the quality of their waking periods is healthier too. The immune system If the immune system is not stimulated by a challenge (not necessarily an infection), it becomes sluggish. Changes similar to those happening in an aged body can occur. Hence, it is essential that a woman practises yoga every day to maintain the health of the immune system. The resistance of the body to infection is less after menopause, as the immune system is partly dependent on the female hormones. Certain specific areas like the urethra, the bladder and the vagina are more affected (for details refer section on the menopausal woman). If she begins practicing yoga in childhood, a woman can prevent the erratic malfunctioning of the immune cells to an extent. During the menstrual cycle too, the genital and urinary tracts are easily prone to infections. Asanas like Baddha and Upavishta Konasana, Supta Virasana, Supta Baddha Konasana and Setu Bandha Sarvangasana promote excellent circulation of immune cells in these areas. All other asanas protect different areas likewise.

Orthopaedic disorders Women are prone to a variety of mechanical problems. In daily life if healthy movements are not practised, the joints will definitely become stiff with aging. Over the years, the continued lack of physical conditioning engenders weak muscles and joints. Arthritis of the finger joints is very common, often found in persons whose fingers are by nature very stiff and inflexible. Puffiness of the fingers with pain, and early morning stiffness are usual complaints. The simplest method to obtain relief is to manipulate them according to yogic principles, and in a few months the fingers will

become supple. The suppleness is to be improved to a level that allows the person to play marbles.

Reverse namaste to make the wrists, elbows and shoulders flexible.

Menopausal and post-menopausal women have a natural tendency to pain in the joints, particularly in the fingers. Early morning stiffness is common. Radiologically, there is no evidence of inflammation in the joints but only of osteoporosis. Blood circulation and nervous energy are sluggish in these areas. Exercises result in fresh blood rushing into the joints, which the woman can feel as the exercise is being performed. After a few months this pain, (due to osteoporotic changes of menopause on account of estrogen deprivation), is resolved. This condition is not arthritis as is commonly mistaken by patients. This is arthralgia and does not cause residual joint damage. Supplementary calcium intake greatly helps to relieve the pain in the joints. Under normal circumstances there is no danger of soft tissue calcification with supplementary calcium. The serum level of calcium remains. Pain in the wrist and inflamed tendons of the thumb are yet other common disorders. Such patients usually have small-sized palms, stiff wrists and are unable to stretch the wrists. Often, the constant use of the hands creates friction of the tendons on the outer side of the lower forearm beneath the thumb — De Quervain’s disease. The wrist must be made totally flexible by practising the reverse

namaste (page 135) and other asanas like Dog pose, Hand stand, etc. This abolishes the pain in all cases and, if practised regularly, prevents relapse. The outer part of the elbow is prone to inflammation. This is known as the ‘non-tennis’ elbow, as in most cases there is no history of having played tennis. In these patients, the extensor muscles of the forearm are very weak, as evinced by the inability to even squeeze the gripper (above right). A healthy solution is to practice asanas like Adho Mukha Svanasana, Hand stand, Elbow stand and Urdhva Mukha Svanasana. Advanced asanas (done if possible) like the balancing poses and Vasishtasana prevent such disorders. If proper techniques are followed in these asanas, relief will result. If this is difficult, or time is a constraint, an easier solution is to train with the power gripper. This ensures strength of the tendinous origin of the extensor group of muscles of the forearm, all of which start from a common point. Use of the forearm will result in pain and inflammation over the years if this area of origin is weak, (as in the case of many women). Many women are prone to frozen shoulders and arthritis due to faulty habits in the use of the joints every day. The practice of elementary exercises for the shoulders goes a long way in preventing these problems. In simple movements like Tadasana (below), for example, the hands are interlocked and the palms turned up and the forearms are stretched vertically to the maximum.

The extensor muscles of the forearm are very weak, as evinced by the inability to even squeeze the gripper.

Tadasana with the hand stretch makes the muscles and joints of the arm elastic.

Concave Uttanasana improves blood circulation in armpits and makes shoulder joints elastic.

Hand stretch holding a window bar behind the back ensures complete elasticity of shoulder joints.

Uttanasana with arms overhead enables healthy reverse movement of shoulder joints.

This position is held for a period of one to two minutes and then released. The same movement is repeated four or five times. Yet another movement is to place the elbows on the table at a particular level (which varies with the height of the person) and press the body all the way down after stepping back to a certain distance. This stretches the region of the armpit and the upper surface of the shoulder joint, and improves the blood flow more than in normal use. Complete flexibility of the shoulder joint in this particular direction is obtained (illustration of concave Uttanasana, above). The other movements which are simple and not too time consuming are, to hold a window bar behind the back with both hands and step forward and stretch the chest erect and to stretch the hands over the head holding a bar (illustration on right). The purpose of my describing these movements is to give the reader an idea of what is involved. This is not meant to be a ‘do-it-yourself’ piece of advice. A common problem is that of pain in the muscles of the neck at times of stress. The shoulders, and the muscles connecting the neck to the shoulders, are also afflicted. Many women have rigid muscles. The relevant muscles have to be consciously relaxed at times of stress. Poor posture of the neck while standing or sitting causes cervical spondylitis (refer medical section on this disease). This affects the alignment of the cervical bones and muscles, causing pain in the neck and the arm. Giddiness with sudden neck movements is another symptom. This is due to pressure on the nerves of the neck interfering with proper blood flow into the back of the brain. Emphasis should be, first, on awareness of posture for, unless we are conscious of it, we cannot rectify the problems it causes.

All categories of asanas relieve cervical problems. Extension movements are important (illustration, next page, top right). Inversions strengthen the cervical muscles. Modifications with the help of props may be needed for some patients. All symptoms of nerve root compression and poor blood flow are abolished by asanas. While resting on a chair or sofa, many women tend to slouch, pressing the abdomen and chest together. This is the most common cause of dorsal spondylitis. Cervical spondylitis is more widespread in homemakers than in their professional counterparts, due to poor posture and lack of movement in everyday life. Both dorsal and cervical spondylitis can be treated with asanas like Adho Mukha Svanasana, extension exercises for the neck like the stretch on the rope, back bend on the rope, Shoulder stand, and half Halasana on the stool. Women often suffer from low back disorders. Poor posture, rigidity of muscles due to lack of exercise, improper beds and mattresses, are the various causes. Painful menstrual cycles are another cause of habitual low back pain, with congestion of blood in the uterus and inflamed pelvic organs. Though there are many causes for low back pain, it is most often a mechanical fault. Standing poses relieve pain (page 139 top left). If the spine is made healthy by using all available poses (back bends, forward and twisting poses), pain is totally abolished. Props may also be used. The asanas work by relieving muscle spasm, improving blood flow, decompressing nerve roots and strengthening relevant muscles and ligaments — in short, toning up all structures (for more details about asanas for low back pain, refer section on yoga and prolapsed disc). Many women complain about their inability to sit cross-legged on the floor, which was a very common posture. This is only due to avoidance of the posture and over years of lack of proper use, arthritis of the hips and knees results. It is important to maintain the flexibility of the groin muscles and the simplest way to ensure this is to sit on the floor for a short period every day. Asanas like Baddha Konasana, Padmasana and Malasana help. All standing poses are useful to prevent arthritis of the hips and knees. Trikonasana, Parsvakonasana, Adho Mukha Svanasana and Uttanasana protect all joints in the lower limbs. If Virasana is used for leisure sitting, the knees and ankles never suffer. The practice of sitting on the floor must never be given up. In some countries, the posture adopted for defecation is one of squatting. While the sitting position on the commode is easier, the intra-abdominal pressure on the bowel is greater in the squatting position. This increases intra-colonic pressure, favoring better excretion of colonic contents. In India it is common for people to squat, with the knees and back flexed, for long periods. Such habits are a good preventive against low back problems. Standing continuously in the wrong manner results in the formation of a calcenal spur in the heels. The uneven distribution of weight causes wasting of the fat pad in the heel as the bone is pressurized. This causes irritation on the surface of the bone and the friction creates spur formation. Yoga teaches the right way of standing. Virasana (page 140) relieve pain caused by spurs in the heels. The placement of a weight or firm pillow on the heels in a particular manner relieves the pain. This asana relieves arthritic pain in the ankles too.

Parsvakonasana using a wall as prop, without need of any special gadget.

Some women complain of body ache at times of stress. On clinical examination this does not fit into any disorder, and they do not get complete relief with any system of treatment, (even yoga), as the problem is due to a stressed personality. Such persons are often emotional and over excitable, and cannot control their mind. Yoga does help relieve the situation. Quieting (hypocreative) poses like dog pose, forward bends, Viparita Karani with bandage soothe the person. Yet a basic change in attitudes is a must.

The menopausal and post-menopausal woman The menopausal woman deserves special attention. Aging of the human ovaries continues throughout life. Menopause is a physiological, not pathological change. The average age when menopause occurs varies with race. In general, it takes place between fortyfive and fifty. In very rare cases, a woman attains menopause in her late thirties. I have discussed below the various changes that occur in the body because of menopause.

Extension of the neck on the rope.

The ovaries The production of estradiol and oestrone hormones by the ovaries ceases at menopause. Androgens are still produced. The ovaries are markedly depleted of oocytes. The size of the ovaries is less than 2 cm. The uterus The uterus shrinks as age advances; fibroids, if any, regress in size. The lining of the uterus is atrophic; supporting structures become weak with loss of elasticity due to poor collagen content. A tendency towards prolapse of the uterus is common.

The cervix and vagina The lining of the cervix is thinner and easily denuded. It is essential to screen for cancer of the cervix at this age. The vaginal lining becomes friable and prone to damage. The ph of the vagina rises from 4.0 or 5.0 to 8.0. The production of glycogen decreases and the area is readily invaded by many organisms. Frequent vaginitis (inflammation of the vagina) with a burning sensation occurs. A feeling dryness is common. Coitus may be difficult. The urinary tract The lower parts of the urinary and the reproductive tracts have a common embryonic origin. The urethra contains receptors for estrogen, and as the lining atrophies to some extent symptoms similar to urinary infection occur. Frank urinary infection is also common. The bladder mucosa is less resistant to infection. Certain tissues support the urethra at a particular angle. These are estrogen dependent. After menopause, there is a tendency for prolapse of the bladder due to weakening of these tissues and stress incontinence results. This results in involuntary dribbling of urine when the patient coughs or laughs, often creating a lot of anxiety for her, particularly on social occasions. The vulva The amount of fat in the vulva decreases and causes a general flattening of the labia majora. The skin is easily traumatized as it is thinner. Symptoms of itching are more common. The breasts The amount of glandular tissue regresses and fibrous tissue increases, resulting in shrinkage of the breasts. The incidence of breast cancer is high at this age. Thorough and regular screening is essential for every menopausal woman.

Virasana with weight prevents inflammation of the heels, by massage.

The skin Dryness and wrinkling of the skin, increased facial hair, areas of altered pigmentation and easy susceptibility to trauma occur. The microcirculation in the skin decreases due to diminishing size of the capillaries. The skin becomes looser and less elastic. Dryness of skin occurs due to poor sweat and sebaceous gland activity. The menstrual change Due to follicular atrophy, the ovaries produce less estrogen and, in response to this, the pituitary levels of follicle-stimulating hormone (FSH) rise. The menstrual cycles become shorter at first, and then lengthen. Menopause is diagnosed if no cycles occur for a period of twelve consecutive months.

The heart and vessels The person suffers palpitations and flushes. Chest pain and fluctuations in blood pressure are more common at this time due to hormonal changes. A woman should be aware of such situations by educating herself about these conditions and seek professional help during menopause even if she suffers no symptoms. The hot flush syndrome The hot flush is the most usual problem for women during menopause. This consists of sudden, unprovoked bouts of a hot sensation in the body, followed by perspiration. The flushes are associated with pulsatile luteinising hormone (LH) release. In some women, flushing is visible in the chest, neck or face which may be accompanied by palpitations. The typical complaint is that the clothes become wet. The reduced level of estrogen influences the level of catecholamines (adrenaline and noradrenaline) in the body. This alters the level of similar chemicals in the hypothalamus, causing this flush. Some women do not suffer flushes at all. The healthier the woman is prior to menopause, the less the symptoms of the hot flush. Associated problems include headache, nausea and extreme fatigue. These flushes are not related to racial, socio-economic or any other factor. The person is particularly distressed by the flush as it often leaves her tired. Reassurance, with an explanation of the mechanism and the fact that a definite solution can be obtained, is important in providing her mental comfort. The locomotor system The deposition of calcium on the bone is estrogen dependent and the resorption of bone exceeds bone formation. Estrogen deficiency also decreases the healthy absorption of calcium from the intestine. This makes the bones fragile and the architecture of the bone cells, (that are woven into a particular pattern for strength), is compromised. The woman therefore suffers from bone pain, and the incidence of fractures is high in this age group. The person is less agile, but this is more a lack of physical conditioning than the menopausal effect. The nervous system The most widespread, oft mentioned and discussed change is that of depression. Others include nervousness, irritability, excitability, and headaches. Altered sensations in the hands (paresthesia) occur. Menopausal depression sometimes becomes severe. Sleep disorders of menopause The reducing levels of estrogen cause sleep dysfunction. These changes include disturbances in the sleep-wake schedule, fatigue preventing a healthy slippage into the sleep phase, and hot flushes waking the woman from sleep.

How does a woman deal with menopause? Menopause is a natural change affecting the human body. It is also a process of birth control. Women should accept it and should never fight the situation. The greater the physical and mental resistance, the more is the discomfort. This is similar to the premenstrual syndrome. Attitudes towards a situation determine the stress on the mind and the body. A healthy attitude prevents problems like depression. Women who are outgoing, search for challenges, and are mentally tough do far better and suffer less depression than those who are introverted, self-effacing and mentally weak. Good interpersonal relationships and effective support from other members of her family will go a long way in helping the woman deal with her menopausal syndrome. If the woman suffers excessively from the side effects of menopause in spite of a healthy attitude, methods are available to combat the problem. Most important is to prepare oneself for this stage by a healthy diet, particularly rich in calcium. This prevents the development of post-menopausal osteoporosis. A maximum of 1500 mg of calcium per day is the recommended supplementary dosage. Renal and gall stones preclude calcium intake. Provided the protein and carbohydrate intake is normal, the only change is in prescription of calcium and exercise. Exercise is of great value. It prevents many side effects of menopause. Women of very low socioeconomic strata suffer less from the effects of menopause, in spite of poor diet. Their lifestyle is one of physical activity, especially in third world countries. Their minds are not clouded by all kinds of theories of menopause, and hence they fit into the change without anxiety. The educated woman’s apprehensions are the greatest problem in tackling health disorders as fear affects proper functioning of the entire system. The microcirculation of the skin is maintained by regular asana practice. The skin is massaged in many directions by various types of tractional forces. These maintain the elasticity of collagen and prevent unhealthy sagging of the tissues. When the skin is well elasticized, it is not easily traumatized. All asanas are useful for this purpose. Each asana benefits different portions of the skin and the manner of stimulus is different. Even if the woman does not practice for a minimum of one hour daily, as recommended, a few asanas will preserve the elasticity of the skin. Inversions are useful to maintain the health of the facial tissues. Standing poses help the periphery of the body. Back bends and forward bends work on the rear and front aspect of the body respectively. Twisting poses work on the spinal and abdominal areas maintaining softness of the skin. The bones are well stressed by asanas. Exercise is a stimulus for bone remodeling, and yoga is ideally suited for this purpose. During asana practice, there is adequate time to adjust alignment and ensure that directional forces are evenly distributed to a particular part of the bone. The result is a healthy bone structure throughout life. However, the superiority of yoga over other exercises or vice versa is not yet established. Logically the amount of stimulation provided by weight training will be superior to yoga as the load can be increased as needed. Exercise also improves the absorption of calcium from the intestine and promotes its deposition on the bones.

Regular asana practice, starting at an early age, reduces much of bone pain. Standing poses are highly useful in this regard as the alignment is precise and the appendicular part of the bones derives maximum benefit. Balancing asanas, if done properly, are useful in maintaining the load-bearing capacity of the bones. Back bends and forward bends strengthen the front and back portions of the vertebral column. No part of the body is neglected; even the little toes are used. In no other system of exercise is the concept of alignment, centering, and a controlled force stressed upon. Asanas such as Baddha Konasana, Supta Virasana, Upavishta Konasana, forward bends and back bends maintain the softness of the vaginal walls and the vulva. Symptoms such as dryness in the vagina and itching are prevented. Coitus becomes easier. As these organs are soft in consistency (unlike bones), it is easy for asanas to sustain health. The lining of the urethra is massaged and the blood flow maintained. Immunity of the urinary tract is well provided and the woman does not suffer frequent infections. Regular exercises maintain the health of the urethral tissues even though estrogen levels decrease in menopause. Stress incontinence can be corrected. Supta Baddha Konasana is invaluable, as it lifts up and strengthens the angle of the urethra. In addition, if prolapse of the bladder has occurred, the woman can feel the lift of the organ in the pose. Concave forward bends are highly useful to lift up the prolapsed bladder or urethra. Prasarita Padottanasana and Uttanasana done with the back concave, Adho Mukha Svanasana, Maha Mudra, Baddha Konasana, and Upavishta Konasana with a concave spine all benefit weakened pelvic organs. If the woman practices a few of these poses regularly, degenerative changes seldom occur. The uterus is stimulated and its blood flow enhanced by these asanas. Inverted asanas like head and Shoulder stand drain venous blood from the pelvic organs to a greater extent and provide fresh arterial blood, revitalizing the organs. The supporting ligaments of the uterus remain strong as all asanas help maintain elasticity and strength. Inverted poses done with the contraction of the perineal muscles and an upward stretch of the thigh muscles with a rolling action strengthen the pelvic floor muscles and lift the organs upwards. Guidance is needed for such sophisticated practice. It is erroneous to think that, once the inverted pose is completed, the organ will prolapse again. Strengthening of certain muscle groups in these poses always maintains the proper position. Back bends, which have a specific shape, are highly useful. In these poses, the perineal and anal muscles are worked to the maximum, in terms of both strength and alignment, in the geometric shape of the asanas. The symptom of hot flush is vaso-nervine in nature. Regular exercise prevents vasomotor instability. Asanas and pranayama, particularly the latter, give the greatest vaso-nervine stability to the system. Women who practice pranayama do not suffer much from the problem of hot flushes. The use of the bandage on the facial tissues is essential. The organs of perception are taxed to the maximum at the time of menopause due to nervine and hormonal changes. This is best tackled by Shanmukhi Mudra and pranayama. Prolonged bouts of practice are very beneficial. Pranayama practice can also be introduced with benefit for the homemaker who has never done yoga before. Forward bends reduce the severity of hot

flushes, as they regularize the activity of the sympathetic nervous system and prevent electrical malfunction. The so-called natural changes of the body can easily be regularized by the yogic system. Inversions also work on the regulation of the central and the autonomous nervous systems, controlling hot flushes and lack of energy. In the menopausal period, the fat accumulated in the lower abdominal area presses on the pelvic organs, and drags them forward and out of position. Over the years, a prolapse occurs. Some of the poses down with the back concave as in Baddha and Upavishta Konasana help the condition. These can even be done after a full meal. All the concave poses can be practiced during the menstrual cycle. Precision has to be observed while practicing the poses to get the maximum benefit. Unless exercises are done, the ligaments and muscles are not toned up and the condition recurs after a few years. There is no need for hormone therapy to strengthen the tissues if asanas are practiced regularly. As the health of the internal and external genital organs is maintained, sexual performance is unaffected. Persistence of sexual desire is dependent not only on proper endocrine function but also on the mind. A healthy approach to sexual function after menopause depends upon the husband too. He has to understand the changes that his wife is undergoing and adjust accordingly. With all this support mentally and physiologically, a woman can face menopause without strain. In some women with intractable symptoms, replacement therapy with estrogen may be needed. This carries the risk of cancer of the endometrium and breast. Other complications include thromboembolic disease and high blood pressure. The risk of gallstone formation is high. It is impossible to predict who will suffer and who will not, and so replacement therapy should be implemented carefully. It should not be recommended as a matter of course. The first step is to accept nature’s change in the system. Exercise and healthy diet are more efficacious remedies than hormone therapy, for it is unnatural to reverse the physiological functions. Hormones have to be discontinued some day!

Exercise vs drugs In all the disorders that I have discussed above, a woman would benefit more by exercise, specifically the yogic asanas, than by resorting to pharmaceutical treatment. Every ailment can be controlled by drugs — thyroid deficiencies, obesity, menopausal problems, diabetes, heart disease, intestinal afflictions, orthopedic disorders, migraines, and insomnia. It is only the parameter of exercise that can prevent the diseases from occurring again. In fact, a regimen of regular yogic exercise will prevent such illnesses from occurring. Exercise is like food to the human body, nobody can afford to be without it. A woman should adopt the maxim that prevention is better than cure. It is the wife and mother who have to set the example. She is the one who is responsible for the health of her family. Once she realizes the need for a proper lifestyle, with a good diet, adequate exercise, sufficient relaxation, and correct sleep habits, she will ensure that everyone in the family — starting with her — keeps to it. The role of yogic principles in a woman’s life By basing her life on the eight-fold principles of yoga, she develops proper perspectives to deal with

her world, whether it is confined to just the family or also includes professional work. It is not the practice of asanas and pranayama alone that will help, but the uncompromising observance of the yamas and niyamas. Ahimsa is achieved by a gentleness of approach towards everybody, especially the elders in the family. Children look to their mother for guidance in whatever they do, and the mother who is quick to show them that the best way in any situation is to be truthful to values and principles will certainly shape the future generation well. The temptation to compare themselves with their neighbors and wishing to ‘keep up with the Joneses’ is a common failing. The Yoga Vasishta says: “The person struck by desires cries, falls and is bewildered. He goes to the state of meanness with visible dejection, his mind frustrated and vitality destroyed.” (Samvid, op.cit., p 1972) The woman must cultivate aparigraha and put an end to the cycle of desires. Each person and family is different, with differing values and lifestyles. One must decide what is right and best for oneself, and stay with it. The niyamas should be part of a woman’s daily life. Saucha is something that she should take particular care -for her family’s health. Contentment follows the realization that she is held in affection and esteem by all in her circle, which is achieved by her own behavior. She should develop the quality of tapas, the burning desire to cleanse our cells at all levels, physically and mentally, so that all around her will have inner strength and vitality which spreads. Finally, the concept of surrender to a higher force gives her an opportunity to embark on the spiritual path and realize the true meaning of life. Through pratyahara, she develops withdrawal of thought from the noise of the outer world and develops clarity of perception. This is the beginning of enrichment of the mind. If she persists in her spiritual quest, she can refine her personality by concentration and meditation, leading to the settled awareness which is samadhi. The very way of living spiritually reduces stress in our lives. That is why Patanjali began his treatise with the sutra, Atha yoga anushasanam (Iyengar, Light on the Yoga Sutras, op.cit., “Samadhi Pada”). Atha means a prayer, benediction or good omen; anushasanam means a code of conduct or precepts for living. Patanjali did not have sanyasins or recluses in mind when he started teaching yoga. His code of conduct is for the common man and woman, for you and me. If we are observant, we notice that when our inner harmony is disturbed, the entire system malfunctions. Patanjali says: “The ceaseless flow of discriminative knowledge in thought, word and deed removes ignorance, the source of pain.” (ibid, “Sadhana Pada,” II.26). We need sound judgment in everything we do, and this, combined with right knowledge, prevents misery.

The Pregnant Woman and Yoga Pregnancy A new dimension in a woman’s life, a state of poise and grace — is one of the greatest experiences in life. Nature often has its own methods and order. Pregnancy should normally sail smoothly, as it is a marvel of nature. Things go awry only when we meddle with nature’s working. Many decades ago the setting of child birth was the house with experienced womenfolk assisting the mother. Sometimes, the local midwife was called in. Today, the entire scenario has changed. Particularly in urban areas, across the strata of social class, deliveries are usually in hospitals. Sophisticated equipment is available to meet any emergency. Medical management of pregnancy has advanced to such a large extent that surgical procedures can be done for the fetus in utero. Fetal blood transfusion and corrective repair can be done for the baby, genetic manipulation is possible. Despite this, pregnancy presents many problems for the woman now. She is exposed to environmental pollution (including nuclear irradiation), adulterated water and food, high noise levels, passive smoking and alcohol, etc. She may have poor dietary habits, either eating too little or too much. She may be an alcoholic, a smoker or a drug addict. Her life could be full of stress. All this has an important bearing on the entire period of her pregnancy. The fetus bears the mark of the mother’s lifestyle. In preparation for motherhood, it is essential that she leads a healthy life, both physically and mentally (not just during pregnancy). She must have a sensible diet, keep active, and must try to prevent illnesses. Weight gained during pregnancy is acceptable but this sensitivity should not be altered by faulty eating habits. An enhanced quantity of protein and carbohydrates, along with essential vitamins and minerals, is needed, with less of fat. Supplementary vitamins and iron are normally prescribed. At the same time, there is no need ‘to eat for two’, as the popular advice goes. Overeating leads to undesirable gain in weight with its attendant problems. A healthy digestive system ensures good absorption and healthy growth of the baby. Proper elimination of bowel contents removes toxins. Constipation, due to poor fiber content in the diet, is common. Unless there are contraindications, the pregnant woman should be very active and must have an exercise routine. Flexible pelvic floor muscles are very important for a comfortable delivery. Health

levels of activity during pregnancy reduce the chances of uterine muscle inertia during labor. Post delivery, the uterus shrinks to normal size faster in a woman who has been physically active. Many antibiotics have adverse effects on the growing embryo and abortions are sometimes due to chronic infections. Even common colds must be guarded against, let alone diseases like AIDS. The organs of the baby are formed in the third month and any drug administered at this time can deform the fetus. All drugs ingested also cross the placental barrier and affect breast milk. Hence, the pregnant woman and the nursing mother should be prudent with their health to ensure a sturdy baby. Proper recuperation and regular hours of rest are essential. Healthy sleep is very important. Erratic hours of work produce severe stress on the nervous system. This leads to exhaustion and high blood pressure which necessitates drug therapy during pregnancy. Sometimes the pressure remains uncontrolled, and causes miscarriages. The elevated pressure usually returns to normal after delivery. Owing to hormonal reasons, controlling blood pressure during pregnancy poses more of a problem than in a normal state. The emotional state of the mother has a great influence on the health of the fetus. Our ancient sages have advised pregnant women to avoid violent thoughts and emotions, and participation in violent situations. Abortions can occur if the pregnant woman is constantly in a state of mental tension. If the mother has a cheerful, calm and well balanced personality, she will give birth to babies of a similar temperament. This cannot be ascribed to just the genes; the fetus in the womb is affected by the emotional ups and downs of the mother. Western medicine has accepted that emotions can affect pregnancy. The professional woman who conceives has to be extra careful in following all these guidelines. She is exposed to more stress and is prone to poor eating habits, passive smoking, irregular working hours, less leisure time, more emotional anxiety in having to manage home and work. Awareness that she should not develop unhealthy habits is half the battle won. Once she is particular about maintaining a healthy lifestyle during pregnancy, she can continue working until delivery. Many women have a poor awareness of their own physiology. The preceding paragraphs will give us an idea of how sensitive the needs of the pregnant woman are. If there is an elementary knowledge of the female body, it is easier to understand the role of medicine and yoga in pregnancy. In the following pages, I have dealt, with the basics of female hormones, the menstrual cycle and the physiology of pregnancy; care to be observed for the mother after delivery, etc, before going on to the role of asanas in this field and how the guidelines given by Patanjali are invaluable today.

The female hormones The hormones in a woman’s body are of two kinds — ovarian and pituitary. The ovarian hormones The ovaries are mainly concerned with the production of estrogen and progesterone. They also secrete androgen, the male hormones, in small quantities. All female hormones are synthesized from

the basic precursor — cholesterol. The most important estrogen product is estradiol. It is produced by the lining of the ripening follicle. It forms the secondary sexual characteristics — scalp, pubic and axillary hair, breast development, and the feminine curves. It is concerned with the stimulation, growth and proper development of the secondary sexual organs — the vulva, the vagina, the uterus, fallopian tubes, and the breasts. It helps the infantile uterus mature and aids powerful contraction of the uterine muscles. Estrogen is responsible for the development of the uterine lining during the proliferative phase of the menstrual cycle. In the fallopian tubes, it stimulates vascularity, better ciliary movement, and contractile capacities. It is the most important factor in the proper breast development. Estrogen has a feedback action on the follicle-stimulating hormone (FSH). It depresses FSH secretion but stimulates the secretion of the luteinising hormone (LH). Estrogen inhibits follicular activity in the ovaries. It promotes deposition of calcium on the bone; lack of this during menopause leads to development of post-menopausal osteoporosis. The softness and pliability of the female muscles are due to the action of estrogen. Progesterone, though also secreted by the ovary, is secreted mainly by the corpus luteum. It is essential for the maintenance of pregnancy. After the corpus luteum degenerates and the placenta is formed, the latter secretes the hormone throughout pregnancy. Progesterone alters the lining of the vaginal epithelium and the consistency of the cervical mucus, and raises the tone of the muscles of the cervix. The main action is on the uterus where the hormone increases the size of the muscular lining of the organ and the quantity of fibers. It also increases uterine contractions. It enlarges the glandular apparatus of the uterus and increases their secretory activity. Progesterone also helps breast development in conjunction with estrogen. Progesterone is supposed to increase and then inhibit the release of the hormone LH. Apart from their action in the female genital organs, estrogen and progesterone cause retention of salt and water in the body. Progesterone makes the skin and scalp greasy by increasing the sebum content. This explains the acne seen in many young girls in the premenstrual period. Progesterone relaxes smooth muscle (refer section on muscles of the body for clarification on smooth muscle) throughout the body, accounting for varicose veins, enlarged veins in the rectum, and constipation during pregnancy. Both the hormones soften the ligaments and muscles of the body, especially in the pelvic floor, in preparation for pregnancy, to allow the soft stretch of the muscles for delivery. The pituitary hormones The hormones of the pituitary also influence the genital organs and breast. The rear part of the pituitary releases a hormone oxytocin which stimulates powerful contractions of the uterine muscle. The other hormone from this part of the pituitary is vasopressin. It maintains blood pressure and retains water in the body. It is in the front part of the pituitary that the important hormones — the follicle-stimulating hormone (FSH), the luteinising hormone (LH), the melanocyte-stimulating hormone (MSH) and prolactin are

released (for further details about the pituitary gland, refer section on the endocrine system). FSH and LH are together known as gonadotrophins. FSH is a protein which stimulates the growth of the follicle from which the ovum is released. It makes the follicle secrete estrogen with the help of LH. In conjunction with LH it causes ovulation. Apart from this, LH is responsible for the formation of the corpus luteum and the secretion of progesterone. Prolactin stimulates mammary growth and initiates the secretion and maintenance of breast milk. It is secreted in bursts, particularly during sleep. It is under the influence of the hypothalamus. MSH is responsible for the pigmentation of the human skin by increasing the number of pigmented cells (melanocytes). In the second month of pregnancy, the rise in levels of this hormone explains the pigmentary changes seen on the skin.

The function of the ovaries Other than the release of hormones, the function of the ovaries is the production of ovum. The formation and maturation of the ova The ovaries of the child at birth contain all the primitive cells necessary to form the ovum. There are an estimated 300,000 to 500,000 primary cells, but this number is halved by the time of puberty. Out of these only around 5000 become mature, the rest die. Ovulation is the process by which the ovaries release the ovum. Ovulation precedes the activity of menstruation, and the regular ovulatory cycle does not occur until two to three years after the first menstrual cycle. Ovulation occurs till the age of forty-five to fifty after which the organs atrophy. The adult ovary sheds an ovum around the 14th day after the onset of menstruation. These fourteen days form the follicular phase. The second phase is the luteal phase, when the follicle which is empty, (as the ovum has been shed), develops into the corpus luteum. The whole cycle is completed in approximately twenty-eight days. Under the influence of FSH, a follicle ripens. LH helps in this process. The follicle, under the influence of LH, secretes estrogen. This, in turn, has three functions. It causes proliferative changes in the lining of the uterus, inhibits further secretion of FSH, and stimulates secretion of LH. Under the influence of LH, ovulation occurs. The mature follicle ruptures and the ovum is wafted into the uterus. Usually, only one ovum is released each month. The remainder of the follicle is converted into the corpus luteum. The corpus luteum secretes progesterone. This serves two functions. It causes further changes in the lining of the uterus in preparation for the implanted ovum and also inhibits additional secretion of LH. If the implanted ovum is fertilized, the corpus luteum survives and the cells of the ovary secrete the hormone, human chorionic gonadotrophin (HCG). This ensures survival of the corpus luteum. If fertilization does not occur, the corpus luteum degenerates.

The menstrual rhythm Menstruation is peculiar to apes and humans. This cycle repeats once every twenty-eight to thirty days or so, from menarche to the onset of menopause. The first four to five days are those of characteristic bleeding. The rest are divided into two parts — the proliferative and the secretory phases. Around the 14th day, i.e., in mid-cycle, ovulation occurs. This is variable (by a day or two). The twenty-eight day cycle is influenced by a number of factors like endocrine control, the psyche, environment, food, sleep and metabolic disorders. The proliferative phase — repair of the uterine lining If fertilization does not occur, the hormonal support to the uterus is withdrawn, (as the corpus luteum degenerates) and the inner layer of the uterus sloughs off resulting in the characteristic bleeding. The arteries of the inner lining constrict and the lining of the uterus becomes devoid of blood supply and naturally breaks off. The bleeding represents nature’s method of informing us that pregnancy has not occurred. The quantity of blood lost is around 50 to 200 ml. The duration of bleeding is around two to five days. The inner lining becomes intact within two or three days, and in ten days (the termination of the proliferative phase), the thickness of the inner lining is around 2 to 3 mm. This phase is influenced by estrogen. The secretory phase — preparation of the uterus for fertilization This begins around the 14th day of the cycle. The glands in the inner lining of the uterus increase in number (the lining becomes thick to the extent of 5 to 7mm) and being rich in glycogen, fructose and glucose, act as a source of nutrition for the fertilized ovum. Around the 22nd or 23rd day this growth ceases. If fertilization occurs, pregnancy ensues and the corpus luteum survives for ten weeks. If not, the blood supply to the inner lining reduces and the sloughing process begins. This phase is influenced by progesterone. The sloughing of the lining is due to withdrawal of both estrogen and progesterone. The menstrual discharge The discharge consists of the inner lining of the uterus, liquefied blood, red and white blood cells, mucus from the lining of the cervix and the vaginal canal. Menstrual blood is peculiar in that it does not clot, as the necessary clotting substances are deficient in quality. The bleeding occurs from broken arteries, veins and tissues. The bleeding is reduced by constriction of the arterioles and if this is excessive, painful cramps in the lower abdomen occur. Excessive bleeding makes the person anemic. The uterine muscle contracts actively during menstruation. The muscles of the cervix are tighter during the proliferative phase. The secretion of the glands of the cervix brings forth rich watery mucus during the ovulatory phase. This liquid is permeable to sperm penetration, but in the later luteal phase, the mucus becomes thick and resistant to sperm entry and forms a plug at the entrance of

the uterus. The lining of the tubes behaves like that of the uterus. In summary, menstruation represents the breakdown of the lining of the uterus for a pregnancy that has not materialized. This type of menstrual bleeding is known as the ovulatory type, i.e., ovulation precedes the bleeding phase. Can bleeding occur without ovulation? Bleeding can occur without ovulation(anovular menstruation). Sometimes, the follicle ripens but fails to rupture and the ovum is not released. The rest of the cycle occurs as usual and the bleeding starts around the 28th day or so. For practical purposes, regular menstruation means it’s of the ovulatory type. If ovulation is deficient, there are many drugs to induce it. These include clomiphene, tamoxifen, cyclofenil and the gonadotrophins. If the pituitary fails to release the necessary hormones, injections of hypothalamic releasing factors can be used. If the ovary fails to ripen, drugs like clomiphene can be tried. Problems of multiple ovulation and consequent multiple pregnancies is a hazard of fertility treatment. Role of hypothalamus and pituitary There is a feedback loop between the ovary and the pituitary. The hypothalamus stimulates the pituitary to release FSH and a little LH to ripen the follicle. The estrogen secreted by the follicle stimulates more secretion of LH. This stimulates the formation of the corpus luteum and the increase in progesterone levels inhibits the secretion of LH and FSH. In any case, when the corpus luteum dies, the levels of estrogen and progesterone fall. Abnormalities of menstruation Amenorrhea: This means absence of menstruation and, under healthy (physiological) conditions, the causes include puberty, adolescence, pregnancy, lactation and menopause. The pathological (unhealthy) causes for amenorrhea can be many. It could be due to malfunctioning of the hypothalamus, when control over the pituitary gland is lost. Disorders of the pituitary, affecting FSH and LH production, and those of the ovaries, with either poor or excess production of estrogen and progesterone, can cause absence of menstruation. Hypothyroidism, diabetes, chronic infections, poor nutrition, obesity, environmental changes and excess exercise are some of the other factors. The treatment of amenorrhea is that of the cause. This is easier said than done as the causes are many. The encouraging factor is that the cause can be identified and the problem is usually resolved with its eradication. Menorrhagia: This is excess bleeding, in quantity or duration, occurring at the normal cyclic interval. Sometimes the bleeding is excessive and at short cyclic intervals — this is known as polymenorrhagia. If the bleeding is normal, but is at short cyclic intervals, it is called polymenorrhoea. If the bleeding is irregular and out of the cyclic rhythm, it is metrorrhagia. Usually, there is a mixture of all or some of these, and there is never a single cause for the bleeding.

Stress is the most common cause of excessive bleeding today. Many young women suffer from emotional upsets in everyday life and this is most difficult to treat. Disorders of blood (hemophilia, anemia), endocrine disturbances, abortion or ectopic pregnancy, foreign bodies in the uterus, trauma, and infections, all contribute to menorrhagia. Displacement of the uterine position interferes with the proper return of blood from the organ. Fibroid tumors of the uterus most often cause excessive bleeding and necessitate hysterectomy. In endometriosis, the cycles are very short; and in dysfunctional uterine bleeding (DUB), bleeding is painless and characteristically heavy. The treatment is to first clearly identify the cause. Then either drugs, cleaning of the uterus referred to as dilation and curettage (D & C) which many women undergo at some stage in their reproductive life, or surgery (which should be a last resort) are the modalities of treatment. Dysmenorrhea: This is painful bleeding, and can be of two types — pain in the uterus associated with menstruation (true dysmenorrhea), and pain in the other organs at the time of menstruation. About 50% of women suffer from painful periods at some time or other in their lives. Faulty concepts regarding menstruation, use of the menstrual cycle to avoid doing something that is unpleasant, anxiety over the expectation of pain which sometimes never occurs, are some of the causes. Environmental conditions like stress at home or in the office, sexual problems, and troubled interpersonal relationships are the other common causes. The pain is usually felt in the inner thighs and the lower abdomen, or the lower back. It may be severe enough to cause the patient to vomit or resort to analgesics. This disorder can begin at any age. Usually this condition remits after pregnancy and, if the woman takes care to work hard at establishing some changes in her personality in terms of stress reduction, the condition resolves itself. A more detailed description of dysmenorrhea and its treatment is given in the latter part of the book. Is postponing the menstrual flow harmful? Many women postpone their periods for social, athletic, religious and other related reasons. Pills containing combinations of estrogen and progesterone are available and are sometimes overused. Retaining menstrual products is akin to accumulating toxins in the body. If the flow is restrained frequently, the discharge could form kind of coating on the inner lining of the uterus. This could later lead to tumor formation and other functional disturbances in the body.

The miracle of conception The sperms deposited in the vagina find themselves in an acidic medium from which they should escape if they are to survive. Once they enter the cervix, they move rapidly both by their own propulsive power and the contractile forces of the uterus and the tubes. Only those that have survived the initial acidic medium reach the uterus. This takes around one hour. Once they reach the ovum in the tube, they penetrate the egg (after releasing an enzyme which breaks open its covering). Ultimately only one sperm enters, losing its body and tail in the process. The ripe ovum can survive in a fertilizable form only for 24 hours (8 to 12 hours after leaving the ovary) and the sperm for 24 hours. Conception can occur only if coitus occurs from the 12th to the

15th day of the cycle. This is the basis for the rhythm method of contraception. There are exceptions to this rule, and pregnancy due to coitus on any day of the cycle has been recorded. Development of the ovum, the fetus and its membranes The ovum, after being invaded by the sperm, migrates along the tube and by the 21st day has attached itself to the wall of the uterus. It is nourished by groups of specialized cells. As the cells keep dividing and proliferating, the morula is formed. This secretes fluid and forms a cavity called the blastocyst. Inside this blastocyst there is a clump of cells from which the fetus will develop. The outer layer of cells forms the trophoblast, which attaches the ovum to the uterine wall. In one part of the trophoblast, a cavity appears. This is the amniotic cavity. It is surrounded by the amniotic membrane. A second space, the yolk sac, forms. These two cavities are separated by two layers of cells. Between these layers, other cells form the umbilical cord. The cells which attach the ovum to the uterus form finger-like projections into the wall of the uterus, establishing a connection between the maternal and fetal blood systems. These projections are known as the chorionic villi. The cells divide and re-divide and, by the sixth week, all the essential structures of the body are present in a primitive but recognizable form. A part of the chorion forms the placenta which is the connection between the maternal and fetal circulation. This is joined to the fetus by the umbilical cord. The embryo is detached from the trophoblast and is connected to it only by the cord. As the fluid content in the amniotic cavity increases, the yolk sac disappears and the amnion covers the embryo completely. The purpose of the amniotic membrane is to protect the baby. The amniotic fluid acts as a shock absorber, allows fetal movements, and prevents adhesion of the baby to the amniotic membrane. In short, it is the baby’s own world. The amniotic fluid is exchanged every three hours, indicating the enormous amount of transfer of fluid between the mother and the baby. The placenta is the life organ for the baby. It is the fetal lung, exchanging oxygen and carbon-dioxide. It is the fetal kidney, serving to maintain fluid and electrolyte balance and excrete waste products. It is the fetal intestine, absorbing assimilated food products from the mother’s blood. It acts like an endocrine gland supplying the hormones HCG and progesterone throughout pregnancy. It is involved in exchange, as most maternal hormones do not cross the placenta. It transmits maternal antibodies which give immunity against various infections. The placenta grows with the baby. After delivery, it decays and has to be detached from the baby.

Stages of human fetal development First month The embryo is 1 cm long, weighs 2.5 gm, its eyes are two dark spots, its mouth a cleft, and its limbs are bud-like processes. A primitive utero-placental circulation is formed. By the end of the second week, the blastocyst is fully embedded in the uterus. By the end of the third week, the formation of three germ layers — ectoderm, endoderm and mesoderm occur and further differentiation of the

tissues and organs proceeds. In general, the three layers give rise to different structures. The ectodermal layer gives rise to the structures that include the central nervous system, peripheral nervous system, sensory tissues of the eyes, ears and nose, skin, hair and nails, the pituitary gland, the mammary and sweat glands. The endodermal layer provides the lining of the respiratory tract and bladder and forms the tissues of the thyroid, parathyroids, liver and pancreas. The lining of the tympanic cavity and eustachian tube are also part of this. The mesoderm gives rise to tissues that form the supporting layer of the body — muscles, skeletal system, cartilages, and also the heart, arteries, veins, lymph, kidneys, gonads and their ducts, and the adrenal glands and spleen. The respiratory system begins to develop by the end of the fourth to fifth week. The lungs are not capable of respiration till the seventh month. Mature alveoli are not present before birth. The primitive folds of the pituitary gland form by the end of the third week. The development of the esophagus and stomach starts as early as the fourth week. The liver appears as an outgrowth of the foregut in the third week. By the tenth week, it has started its functions. The head and tail fold, and a rounded body form are evident. Second month Fetus 4 cm long, weighs 15 gm, hands and feet webbed, umbilical cord developing, sex not identifiable, anus is a dark spot. The arterial and venous system begins to develop around the fifth or sixth week. The lymphatic systems form around this time. By the seventh week, the heart forms a typical four-chambered structure. The external ear and the brain vesicles are beginning to form around the 35th to the 45th day. The retinal pigmentation is visible, nipples formed, upper lips develop, and the fingers are separating. Cellular differentiation of the kidney begins. The kidney actually ascends from an initial pelvic to an abdominal position due to the growth of the body in the lumbar and sacral regions. The testicular cells begin to produce testosterone and the testis is able to influence the development of the external genitalia to a male pattern. The thyroid gland, which has been forming, reaches the front of the trachea by this time. The differentiation of the cells in the adrenal gland begins around the fifth week. Pancreatic development is an ongoing process. Third month This stage is known as the fetal period. Fetus is 9 cm long, weighs 80 gm, eyes closed, pupillary membranes appear, and nails appear on the fingers and toes, placenta formed. The face is more human-looking. Development of external genitalia is rapid. The thyroid begins to function at the end of the third month.

Fourth month Fetus 16 cm long, weighs 200 gm, sex made out, fine pigmented hair (known as lanugo) seen, primitive faecal material (meconium) found, convolutions of the brain begin forming. Fifth month Length 25 cm, weight 400 gm, vernix caseosa, a sticky material, seen on the surface of the fetus. The fetal movements are clearly recognized by the mother. Several organ systems are able to function, but not the nervous and respiratory systems. Sixth month Length 30 cm, weight 900 gm, skin red and wrinkled, eyebrows and lashes begin to form. In the male baby, the scrotum is empty. The units of the kidneys begin to function. Urine is passed into the amniotic fluid; this fluid is swallowed by the fetus and passes once again into the kidneys to be excreted into the amniotic fluid. Seventh month Length 35 cm, weight 1500 gm, subcutaneous fat deposits begin, eyelids open, testicles move to their position, the child has attained viability. Primitive gas exchange is possible with the fetal lung. Eighth month Length 40 cm, weight 2000 gm, child plumper, hair grows, and nails extend up to the tips of the fingers and toes. Ninth month Length 45 cm, weight around 3200 gm, scalp hair is dark, both testicles seen in scrotum. Full term Length around 50 cm, weight around 3200 gm, umbilical cord has a twist, and nails extend beyond the fingers and toes. Baby is ready for delivery. This wonderful process is particularly affected by nicotine and alcohol. The ill effects of smoking during pregnancy include abortion, high blood pressure, diabetes, hypoxia of the fetal circulation, placental shrinkage jeopardizing the fetal circulation with growth retardation. Alcohol acts likewise, leading to abortions, infertility and passage of alcohol into the baby’s environment. It devastates the body of the growing baby — malformations include facial changes, small teeth, faulty enamel, hearing defects, small skull (microcephaly), and mental retardation. I hope that women smokers, especially pregnant women, will be sensitive to such issues and, after reading this, quit such habits at once.

Hormonal control of pregnancy The fertilized ovum, around the 20th or 21st day, secretes human chorionic gonadotrophin (HCG). Its functions are similar to pituitary gonadotrophins. It prevents degeneration of the corpus luteum and maintains the lining of the uterus. After 60 days the corpus luteum activity wanes. The placenta produces a wide range of hormones. It uses preformed chemicals to produce estrogen and progesterone from maternal and fetal cholesterol. Many new proteins of placental origin have been identified. If the levels of progesterone fall within the first four weeks after conception, there is a possibility that abortion can occur. As for estrogen, all the maternal tissues are prepared for pregnancy by this hormone.

Changes in the body during pregnancy Genital organs The walls of the vagina become reddish and more vascular and the cells are packed with glycogen. The walls are also softer and elastic. The cervix becomes congested and soft, and the glands secrete a lot of mucus which contributes to the excess watery discharge from the vagina during pregnancy. The uterus enlarges progressively. At full term, it is around 500 times its original size. This is due to increase in the size and number of muscles lining the uterus. The inner lining of the uterus becomes soft and vascular and, sometimes, has spontaneous muscular contractions. The tubes and supports of the uterus show increased vascularity and thickening. Ovulation is arrested and the corpus luteum is active till the third month only. Breasts The breasts show many changes from early pregnancy — brown pigmentation of the areola, a secondary brown pigmentation developing around the first one, increased pain and tenderness, increased vascularity, general enlargement, secretion of the colostrum (a thick fluid), increased erectility of the nipples and nodularity of the breasts. Skin The skin bears increased fat and becomes greasy due to increased sebaceous secretion from the glands. Brownish pigmentation occurs, and the linea nigra — a characteristic pigmented line running from the navel to the pubic area — is clearly visible. The elastic layers of the skin get overstretched and rupture, creating the characteristic ‘stretch marks’ of pregnancy. These are permanent, but tend to pale over time. Muscles and joints

The joints of the pelvis and spine become elastic under the influence of estrogen, progesterone and, possibly, relaxin. Relaxin is produced by the corpus luteum. All these make the person prone to low back aches and ligamentous strains. If the woman has not exercised prior to pregnancy, she is prone to backaches and abdominal pain during pregnancy. The heart and circulation The volume of circulating fluids is greater and this makes the heart work harder. The sac enlarges upwards due to the growth of the baby and the heart is pressed and displaced slightly to the left. Due to the pressure of the baby on the major veins (returning blood to the heart) which lie behind the uterus deep inside the abdominal cavity, venous return is impeded and the reverse pressure produces varicose veins. Blood pressure can suddenly increase to uncontrollable levels, posing a threat to continuance of the pregnancy and to the life of the mother. This excess pressure at times affects the retina and the optic nerve, leading to blindness. This can be reversed by proper control of blood pressure. Some women develop high blood pressure if their mothers also had elevated blood pressure during pregnancy. Such women are prone to developing hypertension on a permanent basis after many years. Women who have congenitally deformed valves in the heart can deliver normally if the cardiac condition is stable. The lungs The upward growth of the uterus pressurizes the diaphragm. This, in turn, exerts pressure on the lungs. Breathlessness in the supine position is common. If she is an asthmatic, the problem, sometimes, for hormonal reasons, worsens during pregnancy. If the attack is acute, oxygen supply to the fetus is jeopardized. The drugs used to treat asthma cross the placenta and adversely affect the baby, but have to be used. Women who are physically inactive suffer more from respiratory disturbances during pregnancy. The digestive system Nausea and vomiting occur in about 50% of women in the first three months. After the third month, the stomach is pressed by the enlarged uterus and reflux of acid into the esophagus produces heartburn. Appetite may increase or decrease. Perversion of appetite (desire to eat unusual substances) is not psychogenic; the hypothalamus is the cause. Relaxation of the smooth muscle of the gut causes constipation. Some women find eating difficult, as the enlarged uterus presses the stomach. The kidneys The kidneys have a heavy burden — to regulate the altered fluid status of pregnancy. Any slight malfunction can lead to fluid retention and weight gain. Frequent urination is the common complaint. This is due to pressure on the bladder and increased filtration of urine. The ureters and the pelvis of the kidneys are dilated and atonic. Once delivery takes place, the urinary symptoms resolve.

The glandular system The neuro-endocrine system undergoes adjustment to face the altered hormonal state of pregnancy. The feedback mechanisms are altered to conform to the new situation. There are changes in appetite and fluid intake, increased tendency to deposit fat, and changes in electrolyte balance. The normal FSH and LH cycle is interrupted. In the adrenal gland, production of steroids is elevated, but this is kept in the plasma in an inactive form. The thyroid gland exhibits increased activity, with total levels of thyroid hormones being higher.

Changes in the general metabolism There is increased fluid and salt retention, causing occult edema. There is progressive weight gain to the tune of 1 to 1.5 kg every month till full term. The metabolic rate increases and liver functions are kept at peak efficiency with an increase in blood flow to the organ. If the woman is not careful to ensure a healthy, low fat diet, by increasing the quality of essential vitamins and minerals, along with proteins and carbohydrates, she and her child will suffer severe nutritional problems. The nervous system Neuritis (inflammation of the nerves) develops if the diet is deficient in essential vitamins, particularly those of the B group. In early pregnancy, there is instability of mood with depression and anger, joy and sorrow. Proper understanding and cooperation from other family members is needed. Towards the end of pregnancy, the woman is calm and composed. This is due both to hormonal and psychogenic causes. The woman should never be allowed to suffer any emotional shock, because abortion can occur. The mind should be kept calm as it is the source of all problems. As we know that the nervous and glandular systems are in constant interaction with each other, any sudden change in the mental state affects glandular functioning. Withdrawal of hormonal support occurs, leading to termination of pregnancy. Emotionally, the mother is gearing up for the new phase in her life and, if she is mentally not up to the task, both body and mind suffer.

How is pregnancy diagnosed? Clinical methods Any sudden change in the menstrual cycle, without bleeding occurring on the usual date, should raise the suspicion of pregnancy. In early pregnancy, the main symptoms are nausea, vomiting, amenorrhea (absence of the menstrual cycle), and changes in appetite. Nausea and vomiting may be absent in many women. The genital organs show characteristic changes. The vagina has a bluish discoloration, the cervix is softer than usual, the shape of the uterus is globular and, sometimes, intermittent contractions of the organ can be made out. In later stages, the marked enlargement of the breasts and their additional

changes, colostrum expulsion, palpation of the fetal parts, auscultation of the fetal heart beat are some of the other methods that can be used in diagnosing pregnancy. Ultrasound The ultrasound method can detect the presence of the fetal heart beat eleven weeks after conception. This is very reliable and precedes positivity of the biochemical tests. Many fetal malformations can be made out. The appearance of the fetal sac is so characteristic by ultrasound, that the diagnosis is seldom missed. This method is now in common use to confirm pregnancy. Biochemical tests Biochemical tests to detect pregnancy depend on the presence of HCG in the urine. But, as this gonadotrophin is similar to the ones from the pituitary gland, false positive reactions can occur. The test is carried out by fixing the HCG and clumping it by specific sensitized latex particles. Another method is to inhibit this antibody reaction — here, the HCG in urine or serum is fixed by specific antibodies and these are neutralized. When latex particles sensitized to HCG are then introduced, no clumping occurs as the antibodies have been used up in the previous reaction. The latter is the more sensitive method. Radioimmunoassay HCG is a glycoprotein which has two subunits alpha and beta attached to it. Antibodies have been prepared to the specific beta unit of HCG, and commercial kits are available which can detect pregnancy a few days after conception. A radioactive marker is used in this test. Enzyme assay This has an advantage over the previous method as, instead of radioactive markers, enzymes are used. The presence of enzymes is detected by an added coloring agent. Ectopic Pregnancy Ectopic means out of place. The possible sites where ectopic pregnancies can occur are the fallopian tubes, ovaries, ligaments of the uterus, the abdominal cavity, and the portion of the uterus called the cornu (refer anatomy of the uterus) which may be malformed. Tubal pregnancy Pregnancy can occur if the tube is distorted anatomically in any way, impeding the passage of the ovum. This may be due to pelvic inflammatory disease, injuries, or to previous intra-abdominal surgical operations which have created adhesions on the tubes. Tubal surgery could be the cause, too.

When the fertilized ovum migrates in an abnormal manner to the tube of the opposite side, the fertilized egg is too big to traverse the tube and gets lodged inside it. The tube, being much thinner than the uterus, is incapable of increasing in size. Rupture of the ovum, with hemorrhage, is a definite possibility. The burrowing of the ovum creates decidual reaction, and the decidua separates itself until the pregnancy is terminated. The changes of normal pregnancy occur in the uterus, as it is under the influence of the hormones. The woman has the usual reactions of a normal pregnancy. Tubal abortion The ultimate reaction to a tubal pregnancy is abortion. The contents of the tube are expelled into the abdominal cavity by active contractions of the tube. If this abortion is incomplete, the products of conception are subjected to repeated hemorrhage and converted into the “mole”. This is partly liquefied and that portion of the tube becomes cystic and bulges — this is called a hydrosalpinx. In this process, the hemorrhage can leak into the abdominal cavity forming adhesions which can be infected. Tubal rupture happens if the ovum is lodged in the narrow portion of the tube — the isthmus. The rupture can be into the abdominal cavity or the ligamentary support of the uterus (broad ligament). In both situations the blood clots, leading to infection. What happens to the fetus? The usual outcome is death. The tube is not capable of nourishment or spatial accommodation and the fetus, even if (in rare cases) delivered at full term, dies at once. Diagnosis of tubal pregnancy The placid type: Usually, the patient has a short period of amenorrhea, followed by discharge of blood through the vagina. She may experience sharp pain as bleeding occurs into the abdominal cavity. The decidua is passed out and can be recognized. Sometimes the bleeding per vaginum continues — this is a diagnostic feature. The patient has tenderness in the lower abdomen and in the rectal area, if the blood has tracked nearby. Patient becomes pale due to blood loss and pulse rate is rapid; and examination reveals an irregular swelling in the pelvic cavity near the uterus. The explosive type: There is a sudden onset of pain, severe in the lower pelvic area, after a short period of amenorrhea. The patient is in shock and can die if not attended to immediately. Emergency surgery, blood transfusion to replace lost blood, and supportive measures are required. Unfortunately, this severe clinical condition can be mistaken for acute appendicitis, painful periods, perforated intestine, renal stone colic and a host of other serious abdominal conditions. Treatment The patient is kept under strict bed rest, and any signs of dehydration and shock are corrected. Ultrasound is a reliable method of diagnosis in conjunction with HCG evaluation — an empty uterus

with positive HCG test. Sometimes the blood may be aspirated from behind the vagina to make a diagnosis. Laparotomy (opening the abdominal cavity surgically) is the only method to evacuate the contents. It may or may not be possible to repair the damaged portion of the tube. The ovary on the affected side should be conserved if possible. In cases of tubal pregnancy, the likelihood of the other tube also being abnormal is high. Therefore only 35% of women have a normal conception after a tubal pregnancy. Before the affected tube is removed, the other one is always examined to make sure that it is healthy. Ovarian pregnancy In ovarian pregnancy, which is very rare, the fertilized ovum develops in the abdominal cavity and the corpus luteum is beside it. The general signs and symptoms are the same as those in tubal pregnancy. The pregnancy ends two to three weeks after conception. The affected ovary is usually removed. Cornual pregnancy Another very rare occurrence, cornual pregnancy happens in the cavity of the cornu which does not always communicate with the rest of the uterine cavity. The general signs and symptoms are similar to the preceding and rupture occurs around the twelfth to the twentieth week. On examination, an important feature is an asymmetrical swelling on one side of the uterus which contracts like the rest of the uterus. The affected horn of the uterus is to be removed along with the products of conception. Cervical pregnancy This condition is also rare, and abortion occurs very early. Sometimes, bleeding can be so severe that it may necessitate removal of the uterus. Abdominal pregnancy The usual sequence of events in abdominal pregnancy is for the ovum to develop in the tube. After a few weeks, the contents are expelled through the ostium of the tube and attach themselves to some abdominal organ — the intestine, or the supports of the uterus. The fetus survives for some time, as the placental attachment, though weak, is intact. The abdominal organs which support the placenta react by enlarging their blood supply and their anatomy and physiology is disturbed grossly. The patient gives a history of tubal pregnancy. The pregnancy proceeds with discomfort in the abdomen, pain and intestinal discomfort. The fetus is not easily felt, and the uterus is felt as a separate mass from the fetus. Sometimes the diagnosis is made late and routine use of ultrasound is useful. Very rarely is the condition missed, as ultrasound identifies the empty uterus. Surgery removes the contents. The operation can be dangerous as the abnormal condition of the abdominal organs makes bleeding excessive. In very rare situations, if the patient is unable to conceive otherwise, she is given a chance to continue her pregnancy as it may be the only chance of her bearing a child.

We have, in the preceding pages, discussed conception, fetal development in brief, pregnancy and its effect on the woman’s body, and the methods to diagnose pregnancy. We will now talk about natural threats faced by a normal pregnancy, and medical management of the same.

Abortion — natural threat to pregnancy I have used the term natural threat as it is nature’s method of terminating pregnancy as opposed to artificial means, or through disease and self-abuse. Nature terminates pregnancy if there is some underlying hormonal disturbance or any other abnormality. Medical termination may be needed if the mother’s health is compromised due to illness or the baby has some congenital malformation not compatible with normal life. Abortion is defined as termination of pregnancy before the 28th week, i.e., before the fetus has become viable. But, as every cell has life whether or not conception occurs, we should rationalize this concept and realize that any loss of life from the womb at any stage should be viewed as abortion. Sometimes women are unaware of abortion if there has been spontaneous passage of the products of conception through the vagina. Eighty percent of abortions occur in the second and third months of pregnancy. The sac ruptures and the placenta and the fetus are expelled separately. Causes for abortion Malformations of the fetus and its membranes, where the trophoblast is found to be defective or the ovum is rudimentary. Viral diseases suffered by the mother produce malformations in the fetus. Many drugs do the same. Errors in cell division and chromosomal abnormalities are the other causes. Fetal anoxia (lack of proper oxygen and blood flow) due to the following: a) Poor placental circulation due to high blood pressure in the mother, infection in the placenta, abnormal attachment of the placenta, and its position; b) Strangulated umbilical cord interfering with blood flow; c) Diseases in the mother that lower the oxygen content, like asthma, severe heart disease, lung failure, anemia; d) Anemia in the fetus due to blood disorders; e) Poisons and drugs; f) Injury and fever; g) Endocrine diseases like maternal hypothyroidism (under-functioning of the thyroid), overfunctioning of the thyroid and diabetes;

h) Inadequate preparation of the uterus for pregnancy. The uterine bed is not receptive to the implanted ovum, and the uterine muscle shows poor growth; i) Tumors in the uterus, like fibroids, can occasionally cause abortion though many women deliver normally with the presence of fibroids; j) Emotional shock and mental fright, producing sudden strong uterine contractions which expel the fetus; k) Multiple fetuses which over distend the uterus with their excess amniotic fluid; l) Premature rupture of the membranes — this is due to excessive pressure in the uterus, friability of the membranes and poor tone of the cervical os (refer anatomy of the female organs). The last cause is fairly common. As the cervix is unable to offer support to the bag of membranes, it bulges, and abortion is often painless. This usually occurs in the second trimester of pregnancy. Abortion can result in maternal death due to shock, infection and bleeding. Apart from this, the general health of the mother is compromised for a prolonged period. Abortions can be classified into five major types: Threatened abortion where there is slight bleeding from the uterus but the pregnancy continues as before. The diagnosis is made by the symptoms and physical examination done very carefully. The only way of management is rest in bed and sedation of the patient. If the entire nervous and glandular systems are quiescent, the problem is resolved. It is here that the value of yogic exercises is realized and this is discussed in the later part of this chapter. Inevitable abortion where, in addition to the above features, the uterus contracts, the sac breaks and expulsion is almost certain. The pain is severe due to colicky contractions of the uterus. If there is severe hemorrhage and incomplete extrusion of the products, active intervention is indicated. The uterus is cleaned under general anesthesia and the shock, bleeding and possible infection controlled. The normal menstrual cycle returns four to six weeks later. Incomplete abortion where some fragments of the chorion are retained in the uterus and bleeding continues off and on. On examination of the patient, it is found that the uterus is enlarged slightly and the cervix open, which is a sign that something is still inside. The treatment is to explore the uterus under general anesthesia and clean it. Missed abortion, where the fetus dies in utero and expulsion does not occur. Mummification occurs and the amniotic fluid dries up. Initially, the patient has signs and symptoms of a normal pregnancy. Slight uterine bleeding occurs and can be mistaken for an incomplete abortion. After a few weeks, there is no sign of pregnancy progressing. The uterus becomes smaller and the maternal changes of pregnancy regress. Fetal movement stops and the fetal heart is not heard. The biochemical tests become negative only a few weeks after the fetus is dead, so the best method of diagnosing this condition is by clinical examination and the use of ultrasound which is unmistakable in its guidance.

In the case of a missed abortion, the products of placental degeneration can enter the maternal circulation and cause extensive intravascular clotting and death of the mother due to hemorrhage. Treatment has to be given on a high index of suspicion, for the bleeding starts after the fetus has been dead for a few weeks. The uterus expels the fetus around three weeks after it is dead. Ultrasound diagnoses this condition easily and the woman usually undergoes evacuation of the uterine contents without much trouble. Habitual abortion is the term used if three successive pregnancies have aborted spontaneously. Thorough investigation into the various causes of abortion is needed. Apart from this, in-between pregnancies, the following investigations help clarify matters: blood count and urine analysis; tests to rule out venereal diseases like syphilis and AIDS in the couple; study of the couple’s chromosomal patterns; tests for diabetes, auto immune disorders like rheumatoid arthritis and systemic lupus erythromatosis (SLE), thyroid deficiencies, renal disorders, and uterine anatomical abnormalities; assay of serum zinc and foliate levels. During pregnancy, careful vaginal examination for healthy tone of the cervical area and any other abnormality is indicated. Assay of estrogen, progesterone and HCG will help. With diligent care and monitoring, it is possible, under most circumstances, to ensure the birth of a healthy baby even after repeated abortions. The woman should wait at least five months after the last abortion before she conceives again, having attended to corrective measures shown to be necessary after all the investigations. During pregnancy, she should rest as frequently as possible and mental strain should be strictly avoided. Diet must be adequate. Any hormone deficiency must be rectified. It will be useful to administer injections of HCG till the 36th week of pregnancy in the hope that the corpus luteum does not degenerate early. Ultimately, what is required is a quiet mind and an undisturbed uterus. If this is achieved, the chances of a successful pregnancy are much better. Asanas and pranayama are invaluable for the woman at this stage, as they produce neuro-physiological tranquility. Inverted asanas help avert threatened abortions. Passive back bends on the pillows do the same, increasing the retention capacity of the uterus. All this should be under medical supervision. To abort or not to abort voluntarily is the question faced by many women at some time in their lives. This is a very delicate issue. Unless there are complications in the mother which pose a threat to her life, abortion must always be avoided, as it is self-justified killing of the fetus. Abortion can be deemed illegal if a pregnant woman knowingly submits herself to or personally induces one without authorized medical help. If it is done by quacks, using unsafe implements or chemicals, complications like infection, hemorrhage, shock and even death can occur.

Medical termination of pregnancy Medical termination of pregnancy, however, is allowed in certain circumstances. Some of these are cardiac and renal disease in the mother; chronic pulmonary infections like tuberculosis, pulmonary fibrosis, emphysema; impaired liver function and malignant disorders, where the treatment affects the

fetus. All these pose threats to both the mother and the fetus if the pregnancy is allowed to continue. It is also very necessary to terminate the pregnancy if it is found that the fetus is diseased or malformed. Such situations arise when there is a strong family history of disease or when previous children have been born with grave congenital problems. When the mother contracts rubella (German measles) in the third month of pregnancy, the fetus will almost definitely be malformed. With new advances in medical research, there are several methods today to identify genetic deficiencies. Ultrasound is very useful in diagnosing many congenital abnormalities. Sampling the cells in the fluid of the amniotic sac of the baby reveals a wealth of information regarding abnormalities. Apart from the amniotic fluid, that inside the villi of the placental attachment in the uterus can also reveal genetic disorders. Gene therapy is gaining ground. Around 50,000 genes have already been identified. It is possible to interfere and change defective genes in specific congenital abnormalities; and if there is a paucity of a single gene, it can be introduced into the fetus. The mother who carries multiple fetuses has the option of fetal reduction. Again, if one of two of the fetuses is malformed, it is possible to ensure the survival of the healthy remainder. Medical termination of pregnancy can be carried out by several methods, depending on the stage of pregnancy and the individual condition of the mother. Dilation and curettage is the method adopted if the pregnancy is less than ten weeks old, after which it is hazardous. Under general anesthesia, the cervix is dilated and the products of conception are removed piecemeal. Suction curettage can be used up to fourteen weeks after conception. General anesthesia is used and the contents are sucked into a special container. Conventional curettage finishes the procedure. Very early pregnancies can be sucked through a cannula and this is often an out-patient procedure referred to as ‘lunch time abortion’. Intra-amniotic injections, where a solution of 20% saline, 25% solution of mannitol or 90g of urea in 200ml of saline is infused into the amniotic cavity, causes the uterus to contract and expel its contents. It may take three to five days for this to happen; sometimes the expulsion is incomplete and may require curettage. In 20% of cases this method fails. If the mother has renal disease or high blood pressure, saline or urea creates problems and she has to be carefully monitored. Prostaglandins, which are acidic lipids in the body responsible for chemical interactions, are injected either intravenously or extra-amniotically (the needle is inside the uterus but outside the amniotic cavity) to terminate pregnancies. In the extra-amniotic method, expulsion is delayed for more than a day sometimes. In the intravenous route, the situation has to be monitored carefully and, within a day, the expulsion occurs. Additional curettage is often required. This technique is generally used for mid-trimester abortions only. In abdominal hysterectomy, a hole is made in the uterus to remove the fetus to terminate the pregnancy at any stage. This method permits safe removal of the contents without any other injury.

There are always potential complications in terminating pregnancy. A lot depends on the stage of pregnancy and the condition of the woman’s health. Some of these complications are hemorrhage and shock due to blood loss, injuries to the cervix, rupture of the uterus, thrombosis and thromboembolism, and infections. The psychological effect of terminating pregnancy is very great. Many women fear the outcome of future pregnancies if they have had malformed fetuses. Genetic and chromosomal counseling is needed in such cases.

Contraception The earth cannot sustain the numbers steadily increasing. Besides, there are individual needs for preventing a pregnancy. These include temporary ill-health in either partner; diabetes, high blood pressure, neuroses in the woman; bad obstetric history like blood pressure during pregnancy, injuries in previous pregnancies, and habitual abortions; diseases transmissible to the fetus; proper birth spacing; early marriage, financial constraints and other practical difficulties, including professional difficulties for the career woman.

Methods of contraception The rhythm method If coitus is restricted to the days after ovulation, roughly after the 14th to 16th days, or three days post menstruation, conception can be avoided. The disadvantage in this method is that it is possible only in women with very regular cycles. Incomplete coitus The penis is withdrawn just before ejaculation in this safe, inexpensive method. It can however cause problems like unfulfilled sexual satisfaction, irritability, and failure of withdrawal. Condom Made of fine latex material, a condom covers the penis completely. This avoids transmission of sperm and also of venereal diseases, most importantly AIDS. The disadvantages are that many users do not enjoy sex and fail to use it, especially if they are inebriated. Chemicals Acetic acid, boric acid, lactic acid, hexyl resorcinol, salicylic acid, used singly or in combinations — are in the form of pessaries and are injected into the vagina before coitus. Long nozzles are supplied with these creams and jellies to ensure that they are inserted deep into the vagina. These chemicals are spermicidal and are easy to use, do not interfere with coitus, but are not very reliable. At best they can be used as adjuncts to mechanical devices.

The Dutch cap A saucer-shaped rubber diaphragm with a metal coil spring at the rim, the Dutch cap acts as a physical barrier and prevents the sperm from reaching the cervix. A spermicide must be used along with the diaphragm, which must be fitted into the vagina without distending it. Coitus occurs below it. It needs to be replaced every six to twelve months, depending on its care. Some women find the Dutch cap awkward and uncomfortable. Cervical occlusive caps These dome-shaped appliances might suit women who find the Dutch cap uncomfortable. Fitted over the cervix they are, however, useless if the cervix is damaged or torn. The care and management is the same as that for the Dutch cap. Intra-uterine devices (IUDs) Plastic or metal devices of various shapes are inserted into the uterus to exert a contraceptive effect. The best intra-uterine device is the Lippe’s loop. T-shaped devices such as the copper T are also commonly used. This method of contraception is popular as, once the IUD has been inserted and stays in place, the woman need not fear getting pregnant. Normally, there are not many side effects. Removal of the IUD helps conception. The method of action is not known for certain. The best time to introduce such a device is at the end of a menstrual cycle. After an abortion, it is safer to wait for six weeks or after the first period commences. After ensuring that the patient has no anatomical abnormality which might make the introduction of the loop difficult, the applicator is appropriately placed in the uterus and the plunger releases the device. The patient rests for some time and should be warned about some possible colic pain and uterine bleeding. She is checked at the next menstrual cycle to ensure the position of the loop, and thereafter, at yearly intervals. At menopause the IUD can be permanently removed. The use of IUDs is contraindicated if menstruation is heavy or if in case of a previous caesarean section. If repeated attempts at introducing IUDs have failed, it is not wise to try again. Apart from the risk of cancer of the uterus, IUDs can cause complications such as inter-menstrual bleeding and pelvic infection and inflammation. Injury to the cervix and uterine perforation can occur. Tubal pregnancy can occur with the IUD still in place, and so can intra-uterine pregnancy. The incidence of pregnancy is 2% to 5% in the first year after insertion. Oral contraceptives ‘The Pill’ is probably the most abused drug today. Its advantages— include regular self-controlled cycles, low failure rate, non-interference with unripe ova or with menopause, and the ability to conceive after its discontinuance. This may mislead women to overlook its considerable disadvantages.

Most of the oral contraceptives available are combinations of estrogen and progesterone. There are varying sequences of estrogen and progesterone and the dominant compound is estrogen. The main mode of action is due to the suppression of the FSH cycle by estrogen. Ovulation is inhibited. The addition of progesterone is to prevent heavy withdrawal bleeding. The pill is given from the first or fifth day of the cycle, to be taken at the same time every day, for twenty-one days. If a day is missed, two pills must be taken the next day — one in the morning and another at night. Withdrawal bleeding occurs two or three days after the period of treatment. To make it simple for the woman, the pills are supplied in packs of 28, those of the last seven days being placebos. She can then take the pills every day without the need for calculation. Regular check up of blood sugar, lipids and liver functions are needed. The pill should not be prescribed with a history of jaundice, liver cell disorders, thrombosis or high blood pressure. Asthma is sometimes aggravated by the pill and it is also safer to discontinue it four to six weeks before any planned surgery. The disadvantages of taking the pill are numerous. An individual will not necessarily suffer all the harmful effects, yet it is better to be aware of at least the more hazardous ones. Cancers of the breast and the uterus head the list, followed by depression, lethargy, headaches, giddiness, painful periods and other menstrual disturbances, acne and fungal infections, gain in weight, and increased blood sugar. The pros and cons of taking the pill must be very carefully weighed. Ease of use must definitely not be the deciding factor. Injectable hormones In countries with a population boom, an intramuscular injection of a progesterone compound is used to prevent pregnancies. These upset the cycle, resulting in loss of periods. The contraceptive rate is high, but return of fertility cannot be assured on discontinuing the injection.

How yoga helps the pregnant woman We have discussed the entire topic of pregnancy, its attendant problems and methods of management. Let us study the antenatal and post natal benefits of yoga. Yoga raises the level of body awareness. The outcome of pregnancy can, to a large extent, be influenced by the practice of asanas and pranayama before conception, during the course of the pregnancy and after delivery. This way both body and mind remain tuned to respond very well to the miracle of birth. For pregnancy to occur without any problems, the basic need is for the organs to function healthily and the body to be kept soft and supple. This can be achieved by habitual exercises done during pregnancy else the woman will find it difficult to cope. This applies to very much to the urban woman who lacks physical activity. Exercises other than yoga can damage the growing sac due to the impact induced. Yoga is the only non-impact exercise. Asanas are exercises that are soft in nature and nourish the tissues of the mother and baby in a gentle way. Secondly, yoga can be used in a therapeutic manner to relieve associated problems for the mother. It can even manipulate the baby in a methodical

way and help turn its body at the time of delivery. If practice of yoga is taken up before pregnancy, natural abortions may be reduced. Yoga also serves the contraceptive needs of the couple, as it instills a sense of discipline in them. The woman must practice asanas every day for sustained benefits. All the asanas are designed for the comfort of mother and baby. Yoga maintains healthy uterine space. Hence the woman need not necessarily feel the kicking movements of the baby as there is plenty of room in the uterus! In fact, the baby enjoys the practice. Let us see how the various systems are benefited.

The skin Back bends stretch the skin on the abdomen to such an extent that the cells in the different layers are made warm. Excess fat cannot accumulate in such areas. The blood flow to the superficial layers of the skin is well maintained. With regular practice of back bends commenced before conception, the characteristic stretch marks on the abdomen are greatly reduced. Due to the intense stretch of all the elastic fibers under the skin, the distension of the abdominal wall by the enlarging uterus does not produce any strain. In fact, there is an orderly stretch of every fiber to the stimulus of pregnancy. All asanas are useful for this. Some women have an even pattern of stretch marks. This only shows that the stretch of the expanding uterus has been borne evenly by the abdominal muscles. In the majority, the formation is asymmetrical. Flushing of the skin by fresh blood washes away excess sebum from the glands in the skin. The saying ‘health glows in her face’ is very apt for the woman who practices asanas regularly.

Muscles and joints There is increased incidence of low back aches and joint pains during pregnancy. The spinal muscles, the sacroiliac and inter-vertebral joints become soft and over flexible due to hormonal changes (estrogen, progesterone and relaxin). On the other hand, a person with stiff spinal muscles which do not become softer can suffer pain due to the mechanical inefficiency in bearing the weight of the uterus. The pelvic floor and groin muscles are usually inelastic, though they are supposed to become soft to allow easy delivery. This is due to unhealthy postures and lack of proper usage in daily living (which overcome the benefits of hormonal change). Unless habitual usage of the body is healthy, rigidity prevails. The abdominal muscles with the expanded uterus easily can adjust to different postures of sitting, which must be encouraged. Squatting on the floor, either on the heels or the toes moves the inner groin muscles deep into the pelvis, allowing better elasticity of the lumbar spine. This, in turn, promotes healthy uterine contractions. Sitting on the floor, cross-legged, encourages sideward opening of the pelvic floor muscles. Baddha Konasana stretches the muscles to the maximum, ensuring elasticity of the vaginal and cervical walls which stretch easily to accommodate the baby’s head and body. Supta Baddha Konasana is an efficient pose to help deliver the baby if the woman knows how to allow the uterine contractions to synchronize with her body power. One of the major benefits of

Baddha Konasana is that the episiotomy (the cut made in the vagina to facilitate easy delivery of the baby and prevent irregular tears in the vaginal canal in first deliveries) wound heals very well with almost no scar formation. Thickening of scar tissue never occurs. Upavishta Konasana stretches the vaginal wall and the adjacent rectal front wall (as the uterus lies in front of the rectum) to the maximum. Both Baddha and Upavishta Konasana (see illustrations, page 169) are to be practiced for five to fifteen minutes, twice a day, before or after food. A pillow kept under the pelvis in Upavishta Konasana facilitates better pelvic tilt and relaxation of the pelvic floor muscles. This also relaxes the uterine muscle which gets relief from the constant load of the baby. The spinal muscles, in turn, are stretched, lightening the load of the uterus. Supta Baddha Konasana gives great relief to the muscles of the lower anterior abdominal wall. This area, bearing the maximum load of the uterus in the erect position, is subject to constant heaviness and discomfort as the pregnancy advances. A belt is tied around the lumbar area and the same passed over the thigh and under the ankles and the heels (pulled close to the genital area) for Supta Baddha Konasana (see illustration, page 169). These asanas can be started at any stage by pregnant women who have never done yogic exercises and can be practiced throughout the pregnancy, till delivery. The other asanas which help the pelvic floor muscles are the standing and seated concave poses. Concave Uttanasana (see illustration, page 168) should be done resting the elbows on a table and ensuring that the back is concave from the lumbar to the cervical spine. This creates space and elasticity in the posterior (back) part of the vaginal and cervical wall. Concave Prasarita Padottanasana is done resting the chin on a low stool or table and spreading the legs. These poses can be done either before or after food, a number of times daily (obviously without overdoing it). The spine bears the load of the uterus. Most of the asanas are useful to tone up the strength and elasticity of the spinal muscles (see illustration of the sitting twist, page 168), and can be done till delivery, with appropriate modifications for the enlarging sac. The horse prop is helpful for all the standing poses. The spinal muscles are stretched or contracted in many directions, with stretches and contractions combined in some poses (see illustrations of standing Marichyasana and Ardha Chandrasana, p 167). Uttihita Trikonasana and Uttihita Parsvakonasana (see illustrations, page 167); Parivrtta Trikonasana, Hasta Padangusthasana, Ardha Chandrasana, Prasarita Padottanasana and the Virabhadrasana cycle are useful poses. They are to be done with support for the different parts of the body, according to individual needs. Flexibility and strength of the lateral flexors and rotators of the spine are ensured. No part of the spine is neglected. Backward bending poses tone up the anterior spinal muscles and the spine, which none of the other poses can do to the same extent. They create proper elasticity of the muscles of the anterior abdominal wall, ensuring a healthy stretch to accommodate the enlarging uterus. Seated concave forward bends like Maha Mudra, concave Janu Sirsasana and concave Paschimottanasana give relief to the load bearing muscles of the spine, ensuring suppleness. Consequently, no aches and pains occur as the pregnancy progresses. Dandasana in Sirsasana — supporting the feet on a wall and ensuring concavity of the spine — strengthens the spinal muscles in a way different from standing poses. The latter tone up the muscles in the erect position and different

areas of the spinal muscles relax or contract. In the Head Stand, the situation is exactly the reverse. Half Halasana done on the stool gives rest to the muscles of the lumbar spine, preventing low back aches. In half Halasana, the muscles of the spine which help support the uterus are strengthened and toned. The diaphragm is made elastic and strong, and can stretch to accommodate the uterus easily. All the joints have to be kept supple to ensure adjustment to the increased weight of the body and different strains on different muscle groups. The hormonal changes in pregnancy help in this by softening the ligaments, especially those of the pelvic floor. The ligaments surrounding the capsule of a joint can actually be stretched or contracted by asanas. All asanas are useful to promote flexibility in the joints, each asana in its own capacity depending upon the shape of the pose. For example, standing poses tone up the joints of the hips, knees, ankles and spine — so essential to bear the load of the increased weight. The pelvic joints are strengthened by seated poses like Baddha and Upavishta Konasana, Padmasana, Virasana and Supta Padangusthasana. Thus, the woman has a wide variety of poses to suit her needs. If she prepares her spine by practicing yoga prior to conception, the best results are achieved. All these asanas should be done twice daily, on an empty stomach, empty bowel and bladder.

Standing Marichyasana relieves and prevents low back ache, induces groin suppleness.

Uttihita Trikonasana keeps lateral spinal muscles strong and the pubic cartilage elastic.

Uttihita Parsvakonasana promotes spinal health, expands lateral space for the growing uterus.

Ardha Chandrasana is for groin elasticity, spinal strength and space for growing uterus.

Concave Uttanasana maintains spinal concavity, relieves heaviness of uterus.

Supta Virasana for post prandial fullness, dyspepsia, nausea, acidity and vomiting.

Viparita Dandasana on rack.

Bharadwajasana on pillow relieves and prevents backache, makes room for growing uterus laterally.

Head stand on ropes relieves heaviness of abdomen, prevents varicose veins, improves circulation for mother and child, energises mother, opens perineal floor.

Baddha Konasana with ropes stretches pelvic floor, elasticizes vaginal outlet, relieves heaviness on pubic bone.

Upavishta Konasana opens pelvic floor to maximum, relieves backaches.

Supta Baddha Konasana stretches perineal floor, enlarges uterus, relieves uterine fatigue, aids healthy blood circulation in pelvic organs and easy delivery.

Viparita Karani on pillows relieves leg fatigue, soothes mind, rests heart and lungs.

Shoulder stand on chair facilitates cardio-respiratory fitness, makes room for growing uterus.

Savasana supine makes breathing easier, rests the heart, relieves pressure on the inferior vena cava, helps pranayama.

Savasana with stool relaxes lower abdomen, relieves lower back fatigue, rests diaphragm.

Savasana with pillows, semi-prone, relieves back and groin fatigue, relieves strain on lower abdomen.

The heart The heart is the most important organ in pregnancy as blood and other fluids have to circulate properly to the fetus. Practice of asanas makes the muscles of the heart pump very well, especially Viparita Dandasana on the rack (see illustration, page 168). Healthy blood circulation and oxygenation to the placenta, which is the fetal lung, is thus ensured. A majority of pregnant women do not have good aerobic capacity and pregnancy is an additional burden. As the enlarging uterus presses upwards on the diaphragm, the heart is pressurized. This strains the circulatory system. Normally, the body is able to adapt to all these changes, but not if the aerobic capacity is poor. Pre-pregnancy practice of asanas regulates blood pressure, reducing the likelihood of rise in blood pressure during pregnancy. As mentioned before, control of blood pressure during pregnancy is difficult. To ensure that complications do not occur, forward bends have to be practiced regularly before conception. During pregnancy, forward bends cannot be done in the same manner due to pressure on the baby. Pranayama can be done throughout pregnancy and, as pregnancy advances, it can also be done in a supine position to favor comfortable descent of the diaphragm. Some varieties of pranayama stabilize the nervous system. Viloma pranayama is invaluable for this and useful for both high and low blood pressure during pregnancy. Asanas such as Setubandha Sarvangasana, Viparita Dandasana, Urdhva Dhanurasana, Sirsasana, Sarvangasana and Viparita Karani (see illustration, page 168, 169) help the heart to function at its peak. The improvement in cardiac parameters in these asanas is comparable to what can be achieved by aerobic exercises, yet is achieved without strain. Secondly, the quality of blood flow is soft and wafting to the organs. All these asanas can be done throughout pregnancy with the help of specialized gadgets which help the woman to practice without strain. The asanas are modified as the sac enlarges every month. The gadgets also prevent mistakes in the execution of the asanas; this is vital to the survival of the pregnancy. In fact, the practice of inversions is very good for the baby and the mother. The entire body of the mother gets relief from the strain of gravity due to the extra load and the baby’s circulation is toned. Incidence of varicose veins can be reduced with the practice of Supta Virasana.

The placental circulation is flushed with fresh blood. Circulation is kept well activated and the flow of nutrients into the cells is also enhanced by pranayama practice. Pranayama stimulates lymph flow, thus invigorating better tissue health. The diaphragm which separates the abdominal and thoracic cavities is a sheet of muscle. This must stretch well to accommodate the pregnant uterus and the rest of the abdominal organs. Often, the diaphragm is inelastic. The inability to stretch is manifested as breathlessness, a sensation of fullness, and inability to lie flat as the pregnancy progresses. Proper practice of all asanas, particularly back bends, improves the elasticity of the diaphragm, which stretches easily during pregnancy. As the heart is fed with energy by all these asanas which tone the diaphragm, incidence of low energy levels and exhaustion are reduced in the woman who has practiced yoga before pregnancy. If a woman has undergone surgery for a hole in the heart, it is imperative that she must start exercising, within limits, even as early as three weeks after surgery. This must be stepped up to her normal capacity before she conceives, so that she can bear the strain of pregnancy. Asana practice before pregnancy helps the heart to bear the increased circulatory load even if the hole has not been closed. The pregnancy may well last full term, but the strain is greater with successive pregnancies. The same guidelines apply if the woman has valvular disorders in the heart.

The lungs The lungs draw in and accumulate energy, just as the heart distributes it. Proper elasticity, leading to good vital capacity, is ensured only if they are exercised every day. As the pregnant uterus presses on the diaphragm, this can cause poor oxygenation, easy exhaustion, low energy levels, difficulty in walking on level ground and climbing stairs, (as the pregnancy advances). I have seen many young pregnant women in their early twenties complaining of breathlessness. In addition, if the woman is an asthmatic, breathing problems increase. For a safe pregnancy, an asthmatic woman should ensure that the disease is well under control before she conceives. The offspring of an asthmatic will almost certainly inherit the disease. For an asthmatic mother to have a healthy baby, she must condition her body very well from childhood, with asanas and pranayama. In this respect, pranayama is very valuable for the woman to help avoid severe attacks. Regular practice is essential as asthma is a mercurial disease. All the asanas which benefit the heart also help the lungs. Props are very useful to drain secretions, improve oxygenation and prevent exhaustion of the system. All asanas can be practiced till delivery. During labor, the practice of pranayama eases the tension of uterine contractions, making them synchronized and harmonious to the extent possible. Practice of inverted poses (see illustrations of Head Stand and Shoulder Stand, pages 168-169) trains the lungs to bear the pressure of the abdominal organs. This helps the pregnant woman to bear the load of the enlarged uterus without feeling exhausted. If the asthmatic has improved her condition to the extent that she is able to practice inverted asanas before pregnancy, there is no strain at all on the lungs. Smoking must obviously cease in the interest of the parents as well as that of their offspring. To

neutralize the damage done by years of smoking on the lining of the bronchial tree, pranayama is of great help. It cleanses the cells of the accumulated toxins and improves the clearance mechanisms of the lungs. The energy drawn in by the lungs enriches oxygen saturation of the blood so that the fetus receives pure and abundant quantity of oxygen. If, for any reason, the fetus suffers hypoxia, growth retardation occurs. Practice of pranayama is thus the only method by which these problems can be avoided. If oxygen deprivation to the fetus occurs, the baby is born slightly retarded. The reason for such deprivation could be due to disorders in the lungs of the mother or to poor functioning of the placenta. To avoid this, pranayama practice is essential. The techniques of pranayama can to an extent prevent any cellular malfunctioning. The practice of asanas and pranayama maintains the health of the mother’s lung so that the placenta (the fetal lung) can be well protected.

The digestive and excretory systems Asanas create space inside the body, maintaining the spatial relationship of organs. In pregnancy, the intestines are pushed upwards by the enlarging uterus and this in turn displaces all the other abdominal organs. The optimum functioning of each organ is prevented. Congestion in the stomach because of the constant pressure, affects healthy appetite and digestion. The stomach telescopes into the esophagus, creating a physiological ‘hiatus hernia’ (hiatus = space). A hernia is an abnormal protrusion of an organ into a space where it normally should not be. In a hiatus hernia, the acid from the stomach refluxes into the esophagus. The esophageal area is alkaline in nature, and the acid irritates it. Symptoms include chest pain and irritation in the central abdominal area. This hernia is termed ‘physiological’ as the condition regresses when pregnancy is over. The diaphragmatic muscles are weak, which permits occurrence of hernia. Practice of asanas, particularly Supta Virasana (see illustration, page 168) before and after food, prevents this, as the diaphragm and the abdominal wall are made elastic by back bending asanas. Nausea and fullness in the abdominal organs are relieved by this pose. Varying degrees of pressure in different asanas practiced during the non-pregnant state tone up specific organs. In twisting postures like Ardha Matsyendrasana, the liver, spleen, stomach and intestines are alternately squeezed and released. Thus, a kind of ‘physiological congestion’ and flushing is created in the organs by this massage. This helps the organs to face the pressures of the enlarged uterus very easily. Some women suffer nausea and vomiting till late pregnancy. This is due to pressure on the liver and gall bladder and hormonal alterations. As the liver is a highly vascular organ, with a wide range of metabolic reactions, asana practice prior to pregnancy is important to prevent such problems. In the pre-pregnant state, practice of forward bends with a rotational component added develops strength of the liver and prevents nausea. These poses cannot be done after conception and hence preparation is essential. Asanas tone up the sluggish intestines and colon, helping proper elimination of waste material. If done prior to pregnancy, the cells of the muscle layer of the intestine remain contractile in spite of the hormonal changes which render them flaccid. Thus, proper absorption of nutrients and elimination of

waste matter occurs. During pregnancy, the asanas are done in a modified manner and still help. The kidneys are under physiological stress during pregnancy. They face a greater circulatory load of fluids and filtration is sensitized. Dilatation of the ureters, which occurs during pregnancy, can be prevented by twisting, concave poses like Uttanasana, Maha Mudra and back bending asanas. These stimulate better contractions of the muscle layer of these long tubes. As a result, stasis of urine does not occur and the chances renal infection is reduced. Back bends also prevent pressure of the uterus on the kidneys, ureters and bladder. Frequent urination due to pressure on the bladder by the enlarged uterus is prevented and relieved by passive back bends like Purvottanasana on the bed, Supta Virasana, Matsyasana and Supta Baddha Konasana. The bladder holding capacity increases. In spite of the enlarged uterus, back bends have enough range of movement to squeeze and massage the kidneys. Free movement of blood in the abdominal aorta, which supplies blood to the kidneys, prevents any pressure changes in the renal blood flow. Better renal blood flow indicates better circulation of immune cells to the kidneys. All twisting asanas are very useful in toning the kidneys, ureters and bladder. Concave forward bends like Maha Mudra, Dandasana with a concave back, Prasarita Padattonasana and concave Uttanasana with support are very useful to stimulate renal blood flow during pregnancy.

The nervous system Pregnancy is a state of both physiological and emotional change. Mood fluctuations may occur. In asana practice, the body is subjected to tremendous conditioning, toughening the mind to physiological strain. Yoga, therefore, is the art of using the will to master the mind and the body. The sympathetic and parasympathetic nervous systems are under extra load during pregnancy. A mental or physiological shock, like abortion for instance, affects the mind. In threatened abortion, as discussed previously, quietude of the mind is extremely important for the pregnancy to survive. A quiet mind favors a non-irritative uterus and hence stability of the conceptus. This can be achieved by the practice of pranayama and pratyahara followed by Savasana (see illustrations, page 170). The methods shown do not pressurize the inferior vena cava. Normally, a pregnant woman is taught to lie on her side. In yoga, methods are available for the woman to rest periodically in the supine position. The special method of lying prone is shown. It is very important for the person to position the body as shown. The withdrawal of the senses from contact with the external world produces a stable nervine and glandular system. The response is faster than any drug can produce as the method directly affects the body and mind in a natural way. Tranquillizers do not help in withdrawal of sense organs. They only quiet the mind artificially — the site of action is the brain cells. In yoga, the mind is tackled through the organs of perception. Unless these organs are disconnected from the mind, true quietude never occurs. Drugs do not work on the organs of perception. After an abortion, when a woman conceives, she is naturally apprehensive. This prepares the ground for malfunctioning of the nervo-glandular system. Patanjali’s sutras stress the need for removing the effects of past impressions by the practice of pratyahara and meditation. When the nervine and

glandular systems are involved, mind control assumes importance. Asanas and pranayama strengthen the spinal nerves. The sympathetic chain which lies on the side of the vertebral column is fed with blood by the practice of back bends. This stimulates better contractions of the uterus and prevents uterine atony. The contractions of the uterus depend on the nervo-glandular system. Twisting asanas like Bharadwajasana and Baddha Konasana with twist work on the spinal nerves, stimulating the receptivity of the uterus to the electrical messages. These asanas can be done throughout pregnancy in a methodical manner. Muscles that are regularly exercised retain their responses to situations which demand contraction or stretching. Inverted asanas like Sirsasana and Sarvangasana may stimulate the pituitary and hypothalamus by ensuring a fresh and pure supply of blood. Usually, a healthy menstruation prepares for a healthy pregnancy. The peripheral nervous system is not neglected by asanas, which exercise the uterine nerves controlling the expulsion of the fetus. Thus, proper neurogenic control of the pelvic organs is achieved. Several asanas are good for this — standing poses, twisting varieties, seated poses, especially Baddha Konasana and Upavishta Konasana. The feedback from the pelvic nerves to the spinal column is well maintained. Pranayama is the key to pratyahara and the beginning of sense and mind control. Tranquility of mind produces healthy endocrine changes in the body (see below). Pranayama ensures this by helping the autonomous nervous system to draw energy from the central nervous system which it energizes.

The glandular system The signals given by the hypothalamus to the pituitary to release the necessary hormones for proper menstruation and pregnancy are well regulated. Post-partum pituitary failure is due to the excessive softening of tissues during pregnancy. This needs immediate replacement of all hormones. Asanas prevent excessive softening or hardening of tissues and organs by massaging them. The massaging effects can be demonstrated by an ultrasound study of the relevant organ. Certain organs are inaccessible to massage- the intra-cranial structures. There is a heavy rise in the metabolic rate and energy levels during pregnancy. Post pregnancy hypothyroidism is common. Glandular connections with the dietary raw material for hormone synthesis, and the nervine connections between the glands and the hypothalamus, are well regularized with asana practice. The availability of raw material is ensured by excellent circulation and the latter by the quietude produced. Asanas thus provide proper maintenance of organic functions during pregnancy despite excess strain. An important factor of the protective effect of asanas in relation to the ovaries must be mentioned. Backward bends stimulate better blood flow and oxygen supply as they increase inter-cellular space in the organ. Forward bends prevent drying and physiological dehydration of the ovaries. Inverted asanas drain the ovaries and ensure fresh blood supply. The woman’s body is thus reasonably protected during pregnancy against any dysfunction, e.g.,

premature degeneration of the corpus luteum which can cause abortion. All asanas can be practiced throughout pregnancy, till delivery.

Metabolism Healthy metabolism depends upon three factors — efficient blood circulation, efficient absorption of food to nourish the cells of the body and efficient production of healthy cells from the bone marrow. The use of asanas to ensure a healthy circulation is discussed in detail in the chapter on asanas, pranayama and circulation. Asanas also improve the absorption of food by the massaging action on the intestines. Regular practice of asanas massages the surface of the bones and pushes fresh blood into the cavity and substance of the bone. This helps maintain production of healthy blood cells from the marrow. The rate at which metabolic processes occur is subject to a variety of controls that can either increase or decrease depending upon the type of stimulus. If the metabolic rate is within healthy limits, unhealthy weight gain does not occur. Pre-pregnant practice of yoga makes it easier to achieve the goal of optimum weight as the body can be trained intensively. It is essential to maintain the ideal weight according to both age and height. After delivery, all efforts to bring the weight down to the pre-pregnant state must be made. Salt and water retention occur during pregnancy. This upsets the normal fluid balance in the body and interferes with proper blood pressure maintenance. Edema is the first sign of circulatory malfunction. However this situation need not raise undue alarm. Most of the time, without other complications during pregnancy, the edema subsides after delivery. Asana practice during pregnancy regulates proper water and salt balance and prevents the occurrence of occult edema. This is probably by the action on the kidneys which regulate salt and water balance, hypothalamus which regulates thirst, and the circulatory system which helps healthy excretion of excess fluid. Inverted asanas are the most important, along with back bends. Regular practice is a must, with proper observance of requisite timings for each pose. These actions occur at the cellular level and asanas must be practiced with deliberation. Variations of inverted poses are useful to stimulate the kidneys and liver, which are important for metabolism. Of particular value are Parsva Sirsasana and Parivrttaikapada Sirsasana which are of help in toning the kidneys, ovaries and liver simultaneously. The spleen destroys worn out red blood cells and is one of the areas for immune cell production. In pregnancy, the strain is greater than usual. Asanas push the immune cells into active circulation and enhance immunity. Twisting poses, squeezing the blood cells as the blood passes through the spleen; help efficient functioning of this organ. The effective usage of healthy red blood corpuscles provides a more competent delivery of oxygen to the baby which, in turn, helps adequate metabolic functioning of the baby’s organ. The baby also derives better immunity as the circulation in the placenta is enhanced by asana practice. The thyroid is one of the most important glands involved in regulating metabolic reactions. The mother should ensure adequate iodine in her diet. Practice of Sarvangasana massages the gland and

improves its blood supply (post practice). The pose should be modified as the sac enlarges month by month. The chair is used as a prop. There is an optimum functioning of the nervous system which maintains the metabolic rate at a particular level. Under normal conditions, it is the variation in the responses to the challenges of living that creates abnormalities of metabolic rate, unless the body is affected by specific diseases. Pranayama stabilizes the metabolic reactions by maintaining a balance between the sympathetic and parasympathetic nervous systems. It is the mind which ultimately determines the metabolic rate. If a person is high strung, the cells of the body work at a higher pace than normal and vice versa. Bastrika pranayama creates heat in the body. Sitali pranayama cools the nervous system, reducing the metabolic rate. Nadi shodana pranayama stabilizes the functioning of the sympathetic and parasympathetic, by balancing both halves of the cerebral hemisphere. According to yoga, the pingala nerve has its seat in the right, and the ida in the left, nostril and stimulation of the former causes heat and the latter produces chill in the body. Nadi shodana pranayama stabilizes the functioning of these nerves, thus bringing about a balance in the metabolism.

The reproductive organs The practice of yoga helps the reproductive organs in two different ways. One is to ensure their preparation for the biological functions of pregnancy, by localized action on the nervine and glandular systems. The second is helping the mechanical functions of the uterus — holding the products of conception and preventing natural abortion. Inverted asanas practiced by the pregnant woman are very safe both for the growing baby and her. If there is any contraindication, the guidelines are individualized. The asanas are to be done twice daily, with a minimum timing of five minutes for Head Stand and Shoulder stand. Head Stand and Shoulder stand help maintain a healthy uterine bed. The practice of these asanas provides excellent placental circulation due to the inverted posture of the mother. Excretion of waste products from the placenta is better facilitated. Gas exchange is healthier and the growth of the fetus is healthy owing to an optimum quantity of oxygen uptake. Maintenance of the fetal life organ — the placenta — depends on the health of the mother and asanas have a great role to play in this. Inverted asanas promote healthy blood flow to the ovaries, preventing congestion. Baddha Konasana ensures better blood flow to all the pelvic organs in a gentle manner, while back bends act in a stimulative manner. The contracting and accommodative capacity of the uterus is well maintained by the twisting poses. Proper alignment of the walls of the uterus is maintained by these poses; abnormal implantation of the placenta might be prevented. Normally, the placenta attaches to the back of the uterus and does not obstruct the descent of the baby during labor. Faulty implantation can occur if the front and rear layers of the uterine wall are not well aligned - one area of the wall may be stronger than the other and pulls the placenta to itself. Sometimes the attachment is to the front wall of the uterus and the fetal descent can squeeze the placenta. This (placenta previa) could cause deprivation of oxygen to the fetus. In this variety, there are varying degrees-high, medium and low implantation. A caesarean section may be

needed. Such abnormal implantation could be prevented by regular asana practice which, again, should start before pregnancy. All asanas prevent pelvic infection as the T and B cells circulate well in the pelvic organs. Apart from hormonal control over implantation of the fertilized ovum, there are mechanical factors that are prerequisites for pregnancy to commence and maintain itself. The first is the healthy suction of the liberated ovum by the fimbriae of the fallopian tubes. Any weakness in this action causes the ovum to struggle to find its way into the uterus. Further, the fimbriae have to be very efficient to propel the ovum into the tube; if not, fertilization occurs in the tube itself. Twisting poses may have a role in this regard by promoting healthy contractions of the muscle wall of the tube. The most important function of the uterus is to hold onto the products of conception. To a point, the practice of asanas can control premature uterine contractions due to cellular malfunction. If the muscles of the cervix are weak at the neck, the uterus is unable to hold onto the products of conception and abortion can occur. This weakness is usually inherent. During pregnancy if an internal examination reveals a gaping cervix, all efforts should be made to ensure closure. Some surgical procedures are available for this purpose. Another method is to use asanas which are ideally suited for this function. In inversions, concave poses and back bends, the muscles of the cervix are tightened and the tone improved. The floor of the uterus is lifted and strengthened. It is easier to hold on to the conceptus. The entire uterus is strengthened. The woman should practice these poses throughout pregnancy. This has to be carefully monitored against a regular internal examination. Prior to pregnancy the woman should practice asanas like Malasana, Pasasana, Supta Virasana, seated twists like Ardha Matsyendrasana, back bends like Urdhva Dhanurasana, Viparita Dandasana, Urdhva Mukha Svanasana, and Ustrasana to tighten the cervical outlet. Concave forward bends, both standing and seated, also lift the perineal muscles and make the cervical opening smaller. In addition, by the lift of the uterus away from the cervix, they give relief to the strained muscles of the abdominal wall and perineum. The action of the muscles in back bends and inverted poses has to be learnt from a competent teacher and cannot be given as out-patient instructions. The real role of asanas and pranayama is appreciated when abortion threatens. In general, if the woman begins yoga after she conceives, she may still avail of the protective effect of the asanas. In threatened abortion, if the situation stabilizes elementary asanas like Supta Baddha Konasana, Savasana on pillows, viloma pranayama with interrupted inhalations and soft prolonged exhalations are very useful. The prolongation of exhalation removes any tension on the nervous system. Yoga may thus be a primary tool or act as a supplement to Western medicine in such situations. Yet, if inevitable abortion occurs in a woman who has been practicing yoga, it will always be complete with full expulsion of the products of conception (incomplete abortion does not occur usually if yoga is done regularly). For the next few weeks rest is important. This is followed by asana practice with specific reference to stabilization of the conceptus. Back bends are very important, having the property of retaining the menstrual flow. Immediately after conception, practice of inversions and concave poses, Viparita Dandasana on a rack, Supta Virasana on pillows, Supta Baddha Konasana on pillows (all with more emphasis on timing),and viloma pranayama should

continue. For habitual abortion, the same asanas help. Studies are needed to ratify all these concepts.

Asanas and pranayama after delivery Care of the woman does not end with pregnancy. Proper rehabilitation after delivery is equally important to rejuvenate the body and bring it back to normalcy, fit for the next pregnancy. Improper care in the post-partum period results in poor healing of the cut made in the vagina to facilitate childbirth. Infections are to be strictly avoided. The skin needs to be looked after to prevent unnatural shrinkage with an ugly appearance. The locomotor system should be exercised to ensure healthy functioning. The effect of the strain of the altered bio-mechanics on the body can tire the system. Due to the softness of the tissues, muscles and ligaments, body aches can occur. It is now that care should be taken to prevent exhaustion. Uterine shrinkage is impaired unless the woman returns to an active life as early as possible. Normally, in three months the uterus shrinks to its original size. Infections, retained products of the after-birth, trauma during labor, all cause delay uterine shrinkage. Bleeding can be excessive. For the first three months, no exercises are to be practiced. This is to allow the body to recover. It is also to prevent interference with lactation of breast milk, as exercises alter hormonal responses. The first menstrual cycle begins around this time and exercises can then be re-introduced. The woman executive who has the dual responsibilities of home and work is prone to neglect her body. The stress of work can interfere with lactation and the return of the menstrual cycle. The greater the physical and mental stress, the more erratic is the return of the cycle. Yoga is ideally suited to help the woman to recondition her body after delivery. As the perineal and inner vaginal area may feel tender, movements will have to be carefully introduced. Simple asanas include Supta Baddha Konasana, followed by Supta Virasana, Baddha and Upavishta Konasana. These stretch and squeeze the genital passage very gently, allowing the woman enough time to feel the movement of the muscles. Setu Bandha Sarvangasana on pillows and Viparita Karani are very useful for recovery from the strain of delivery as they are passive exercises. The woman will have to be awake at odd times to feed the baby. Lack of sleep can be exhausting, as it continues for three to four months or till the baby establishes a regular routine. After three months, gradual introduction of inverted poses and passive back bends gives the mother the energy she needs. The woman (who has had repeated abortions) should not conceive again for at least a year till the cellular responses of the reproductive organs and the nervous and glandular systems have changed. This requires regular practice of all asanas and the woman should not be impatient to conceive. High blood pressure during pregnancy returns to normal after delivery. It is now that yoga should be practiced regularly, as good control over blood pressure can be achieved in the non-pregnant state. To prevent elevation of blood pressure during the next pregnancy, forward bends are very useful. For a beginner in yoga, elementary forward bends like sitting cross-legged on the floor (not in Padmasana) and bending forward to rest the head on the pillows can be initiated. As flexibility improves by practice of other asanas, the normal method of practicing forward bends can be started.

The woman should be assessed for flexibility in the different parts of the body and asanas taught accordingly. Generally, women can sit in Trianga Mukhaikapada Paschimottanasana more easily than men, as their pelvic flexibility is better due to biological and hormonal reasons. In this pose, the spinal muscles move forward easily, as the movement of all the muscles is in the same direction. As flexibility improves, Janu Sirsasana and Paschimottanasana are introduced. These poses can be practiced even during menstruation. Other asanas useful in preventing rise in blood pressure are Uttanasana with the head resting on a stool, Adho Mukha Svanasana with the ropes, Setu Bandha Sarvangasana with pillows, and Viparita Karani on the wall. For a full analysis of treatment of hypertension, refer to the section on medical disorders and yoga in the latter part of the book. Practice of pranayama gives rest from the emotional upheavals of pregnancy and delivery. Till delivery is over successfully, the woman is under tension. Pranayama stabilizes the mind and produces tranquility. Using this method, she should prepare herself mentally for the new role of a mother. Viloma pranayama of both types quiets the mind and reduces stress. If the woman has had a caesarean section, the practice of asanas should start only after 6 months and done with extra care. To ensure health of the scar tissue, it must be stretched fully and rigidity of the fibers of the uterus nullified. This is possible by the use of back bends and twisting poses. The former stretch out the entire front wall of the uterus and the latter soften the scar tissue. In this chapter we have seen many facets of pregnancy, management, the effect on the psyche of the mother and the methods to achieve a healthy pregnancy. I hope that reading this stimulates the motherto-be towards a way of living that will ensure health for herself, her children and the family.

SECTION II FUNCTIONAL ANATOMY & PHYSIOLOGY To know one’s mind and body is a paramount necessity for a healthy, peaceful life. It is important that every one of us has a basic working knowledge of the human body. This will enable us to understand more about health and disease, and help us work towards better physical, mental and spiritual health. I have tried to make the subject as elementary as possible. I have first described the various systems of the body — starting with the cell — and then described briefly about how the practice of yoga affects each of them.

The Cells and Tissues We may begin to understand the human body from the individual cell-the basic unit of the living organism. Tissues are made up of many cells; many tissues form an organ; many organs form a system. All these functions are well organized and highly specialized.

Cells A cell (fig 1) consists of a plasma membrane with a number of small structures called organelles, which float in a medium known as cytosol. The organelles are highly specialized structures that include the nucleus, endoplasmic reticulum, the Golgi apparatus, lysosomes, mitochondria, microfilaments and microtubules. The plasma membrane consists of two layers of membranes of fatty material and protein. The outer surface has an electrical charge and attracts water and the inner surface repels the same. This influences transfer of fluids across the membranes. The proteins are markers for immunological identity.

Fig 1 The simple cell.

The nucleus of the organelles is the power house of the cell. This has a cytoplasm. The nucleus contains the genetic material of the body in the form of large double chains of deoxyribonucleic acid — DNA — in a helical arrangement (fig 2). A number of DNA molecules form chromosomes. DNA is made of protein and phosphate sugar molecules. The protein part has adenine, thiamine, guanine and cytosine arranged in a specific pattern.

Fig 2 The double helix of the DNA.

Ribonucleic acid (RNA) transfers information from nuclear DNA to the cytoplasm for protein synthesis. The formation of RNA itself is controlled by DNA. The endoplasmic reticulum is a series of tubules of two varieties, smooth and rough. The smooth type synthesizes proteins like muscle protein and steroid hormones, and is associated with the detoxification of some drugs. The rough type prepares proteins like enzymes and hormones extruded from the cell for use by other parts of the body. The Golgi apparatus consists of folds of membranes which package proteins into secretory vesicles. Lysosomes are spherical bodies that produce enzymes that break down large molecules into smaller particles. The mitochondria are the respiratory apparatus of the cell. They make energy available to the cell in the form of a chemical known as adenosine triphosphate (ATP).

Fig 3 Diagram of a single cell with a semipermeable membrane.

This is derived from catabolism of food, and requires the presence of oxygen. Microfilaments and tubules have contractile properties helping cell movement. They also maintain the characteristic shape of the cell. Particle transfer across cell membranes occurs by the process of diffusion through a semi-permeable membrane (fig 3). This can be active or passive, taking place with the help of carrier proteins or through pores or change in the lipid part of the membrane. Cells divide either by mitosis or meiosis. The latter occurs in the reproductive cells. Mutation is the alteration of the genetic make-up of a cell. This may cause no change in cell function, or may cause some physiological abnormality, or death of the cell. Abnormal cell functions are linked to genetic mutations. Many genes have been identified; it has also become possible to remove abnormal genes and alter cell functions. This has application in many clinical disorders where there are no cures available. All cells in the body are considered involuntary in the sense that we cannot in any way influence their daily functions. It has been shown that an unhealthy lifestyle disturbs the orderly functioning of the cells. Stress on the nervous system is known to exhaust the cells and deplete energy. Cell division is certainly affected by patterns of living.

Racial, dietary, environmental and lifestyle patterns are some of the influencing parameters for the aging process. Cellular functions release toxins. If removal is inefficient, these metabolites can damage the cells. This is thought to cause aging and is also thought to be genetically programmed. Aging is associated with decline in protein synthesis, which affects the turnover of enzymes that protect the cell. Substances known as free radicals are released every day. By definition, this is a molecule containing an unpaired electron. The mitochondrion is the area for radical production and consumption. In this reaction, substances known as super oxides are released. These can react with the lipid membrane and produce damage. The by-products of this damage can interfere with DNA synthesis and inhibit cell division. The cell is endowed with many enzymes to prevent damage by free radicals. In addition, dietary factors like beta carotene and vitamin E are known to prevent oxidative reactions. These are known as anti-oxidants which protect the body from the activity of radical induced reactions. The free radical reactions are known as ‘oxidative stress’ and the cell changes are referred to as aging.

Receptors: alpha and beta The cells in the body have two kinds of receptors, alpha and beta. Broadly, alpha receptors are excitatory and beta inhibitory. However, beta receptors in the heart are excitatory and their stimulation leads to increase in heart rate and force. In the intestinal tract, both receptors are inhibitive-stimulation produces relaxation of the gut. The adrenergic receptors are present on the cell surface. Beta receptors are of two types: beta 1 and beta 2. (The table on the following page summarizes the effects of stimulation of the receptors in different tissues.) Exercise is known to increase the generation of free radicals. As the amount of radicals is greater during intense exercise, more damage could occur to the body if exercise exceeds a certain threshold. The skeletal muscle is known to adapt to the situation of oxidative stress with increases in the level of anti-oxidant enzymes. In other organs, such as the heart and liver, there is a decline in the level of these enzymes. It is important to understand that if our lifestyle does not include exercise, clearance of free radicals will be inefficient. Exercise is a stimulant for healthy protein synthesis which helps replenish the levels of antioxidant enzymes. If the exercise level is excessive, wasting occurs as synthesis cannot keep pace with demand. Physiological and mental stress will increase the drive at the cellular level, increasing the production of radicals. If the stress is excessive, the cells cannot function. If the nerves are weak, a person feels tired. Healthy lungs are also important for the respiratory functions of the mitochondria. During states of stress, the situation is like a bulb receiving a high voltage current in a split second. The filament burns out. The human body, however, can adapt and function for longer periods than the bulb. However, over the years, nervous exhaustion occurs. The basic drive for cellular function is energy. If the demand is faster than synthesis, a state of negative balance will result. With adequate energy levels, the cellular

functions of imbibing materials, respiration and excretion of waste products are efficient.

Tissues Tissues are made up of large numbers of cells. They are classified into four types: (i) epithelial tissue, (ii) connective tissue, (iii) muscle tissue, and (iv) nervous tissue.

Epithelial tissue In epithelial tissue, the cells are packed tight and the matrix is minimal. The cells rest on a basement membrane. Epithelial tissue may be simple or stratified. Simple epithelium is further classified into squamous, cuboidal, columnar or ciliated. The squamous type (fig 4) has a single layer of flattened cells. Examples include the heart and blood vessels, alveoli

of the lungs, and lymph vessels. In the cuboidal type (fig 5), the cubical cells rest on a basement membrane. These cells are involved in secretion, absorption and excretion—for e.g. the renal cells. The columnar type (fig 6) has a single layer of cells resting on a membrane. These line the organs of the alimentary tract. Mucus is secreted by modified cells known as goblet cells. The ciliated kind (fig 7) is columnar, with fine hair-like projections called cilia. These are microtubules which propel the contents of the tube in one direction only. The respiratory and the uterine organs have such tissues. Stratified epithelium (fig 8) consists of several layers of cells. A basement membrane is absent. These cells protect the underlying structures. They are of two types: (i) keratinized, and (ii) nonkeratinized. The former is found on skin, hair and nails, which are dry surfaces. The surface layer is replaced from below. The latter lines areas like the eyes, mouth, esophagus, which are subject to wear and tear. Transitional epithelium (fig 9) is composed of several layers of pear-shaped cells and lines the urinary bladder, allowing for stretching as the bladder fills.

Fig 4 Squamous epithelium.

Fig 5 Cuboidal epithelium.

Fig 6 Columnar epithelium.

Fig 7 Ciliated columnar epithelium.

Fig 8 Stratified epithelium.

Fig 9 Transitional epithelium.

Connective tissue The cells forming the connective tissues are larger than those in the epithelial, and the matrix is in greater amounts. This kind of tissue is found in all organs. There are several types of cells involved: Fibroblasts are large flat cells which produce collagen and elastic material. They are active in areas of tissue injury and repair where they form granulation tissue. These collagen fibers are involved in scar shrinkage. Macrophages are phagocytic. They may be fixed or mobile. They are found in blood, the lungs, liver, spleen and the brain. Plasma cells form specific antibodies and are derived from B lymphocytes. Mast cells produce chemicals such as serotonin, heparin, and histamine. These are released in response to tissue injury. Heparin is an anti-coagulant and histamine mediates inflammation and allergic conditions. Fat cells are known as adipose tissue. They are found all over the body and vary in size and shape.

Areolar tissue This is the most common form of connective tissue (fig 10). The matrix has collagen and elastic fibers. It is found under the skin, between muscles, supporting nerves and blood vessels, and in secretory cells.

Fibrous tissue This is made of collagen (fig 11). Matrix is minimal. It is found in ligaments; forms the outer covering in bones (periosteum) and for some organs like kidneys and spleen; and covers the muscles with sheaths which extend as the tendon. The main function is to provide healthy and strong base material for tissues.

Fig 10 Areolar tissue.

Fig 11 Fibrous tissue.

Fig 12 Elastic tissue.

Elastic tissue Consisting mainly of elastic fibers, this tissue (fig 12) is found in organs which require constant change in shape, like the walls of blood vessels, and the external ear. The main function is to help the body to stretch.

Lymphoid tissue This (fig 13) consists of lymphocytes and is found in the spleen, lymph nodes, and tonsils and in the walls of the small and large intestine. The main function is defense.

Adipose tissue This (fig 14) consists of two types: white and brown. The former makes up around 25% of body weight in healthy persons and is found in the eyes, skin and muscles. The latter is found in areas like the trunk, walls of large blood vessels, and in the nape of the neck. Functions include insulation, cushioning the underlying parts from impact, and cosmetic appearance.

Cartilage Cartilage is firmer than other connective tissues. The cells are less numerous and packed with elastic and collagen fibers. There are three types: hyaline, fibrocartilage, elastic fibro-cartilage. In hyaline cartilage (fig 15), the cells are known as chondrocytes and are bluish-white in colour.

This cartilage is found in joints, attachment of ribs to the sternum, and in the larynx, trachea and bronchi. It provides shape and stability for movement. Fibro-cartilage (fig 16) is tough and flexible. It acts as a cushion between the vertebral bodies called discs, between the articulating surfaces of the knee joint (meniscus), between articulating surfaces of other joints like the shoulder and hip, and as ligaments. Elastic cartilage (fig 17) consists of elastic fibers in a solid matrix. This forms the external part ear (pinna), the epiglottis and the lining of the blood vessels.

Fig 13 Lymphoid tissue.

Fig 14 Adipose tissue.

Fig 15 Hyaline cartilage.

Muscle tissue and nervous tissue are discussed in the sections on myology and the nervous system.

Membranes Membranes are sheets of tissue which cover internal structures. They are: mucous, serous and synovial. Mucous lining is found in the gastro-intestinal and the urinary tracts. The cells are epithelial and the function is to produce mucus for lubrication and proper passage of contents. It also prevents chemical injury and traps foreign particles (as in the lungs). When these cells are filled with mucus, they resemble a goblet and are known as goblet cells (fig 18). The serous membrane (also epithelial) encloses organs in a double layer, e.g. the lungs. The layer close to the organ is known as the visceral and the other is the parietal layer. The heart and the abdominal cavity are the other areas with serous lining. The function is to prevent friction during movement and allow free expansion. The synovial membrane forms the lining of joints (fig 19) and covers tendons. The cells are epithelial. Synovial fluid is produced to allow free movement and reduce wear and tear. Nourishment is given to the underlying cartilages by the fluid. It is important that these structures are well protected by exercise throughout life. Any degeneration in the lining of a joint can produce excessive wear and tear.

Bursae

These are small sacs filled with lubricating fluid. They occur in areas of tight apposition of muscles, bone and ligaments. They serve to smooth movement and act as a cushion. They also enclose tendons as in the tendons of the fingers. Tendon sheaths provide for free gliding movement. These occur in areas where the tendons pass through ligamentous bands, or bony tunnels. In areas where the skin is subjected to repetitive pressure or wrinkling, as in the palm or buttock, bursae provide soft free movement and cushioning.

Fig 16 Fibrocartilage.

Fig 17 Elastic fibrocartilage.

Fig 18 Ciliated columnar epithelium with goblet cells.

Fig 19 The knee joint: Section viewed from the side.

All the tissues are prone to pathological injury induced by conditions like infections, inflammation, cancer, genetic alteration in their functioning, aging, changes in temperature, immunological reactions, and nutritional imbalances. Four intra-cellular systems are vulnerable to injury: the cell membrane; respiration and the production of the energy chemical, adenosine triphosphate (ATP); synthesis of enzymes and structural proteins; and preservation of the genetic apparatus. The morphological changes of cell injury become apparent only after the biochemical system has been deranged. The injury to cells can be reversible or irreversible. An example of reversible injury is the fatty change induced in the liver due to intake of alcohol which changes to a normal pattern after abstinence. An example of irreversible change is that of a cancerous cell. Atrophy of cells can be due to decreased workload; loss of innervation, blood supply and nutrition; endocrine stimulation and aging. Atrophic cells are not dead but hypo-functioning. Accumulation of material inside cells causes injury. Other cellular alterations include hyperplasia (increase in number of cells), accompanied usually by hypertrophy (increase in size). The former occurs, for example, in conditions like hormonal

stimulation. An instance of the latter is that of increase in the size of the heart in hypertension. Metaplasia is a reversible change in response to a stimulus, e.g., smoking. The cells are replaced by others. Neoplasia is cancerous change. Repeated metaplasia can result in neoplasia.

The Skin The skin is the largest organ in the body. It is an organ of perception and the principle organ of the sense of touch. It also has excretory and absorptive functions. It consists of a vascular layer named dermis, with an external covering known as epidermis. The sweat and sebaceous glands, with hair follicles, are embedded in the skin.

The epidermis This is non-vascular and the cells are stratified epithelial. It prevents evaporation of water from the body. In some parts of the body it is thick, as in the palms and soles. From the level of the dermis, the surface of the epidermis is ridged with furrows, forming the ‘lines of destiny’ and the finger prints. The epidermis consists of several layers of cells in four strata (fig 20). The topmost layer has a substance known as keratin which gives the skin its toughness and makes it water proof. The color of the skin is due to the pigment cells in the epidermis. Healthy levels of oxygen saturation in the blood give the skin its glow and pink color. The bile pigments are responsible for the yellow color of a patient with jaundice.

The dermis The dermis (fig 21) is highly elastic. It has numerous blood vessels, nerve endings and lymphatics. The nerve endings are sensitive to touch, temperature, pressure and pain. The dermis has two layers. The papillae, which are touch sensitive, are found in the second layer. The skin is very thin in the penis and eyelids to allow stretching.

Appendages to the skin These are nails, hair, the sudoriferous (sweat) glands and the sebaceous glands. Nails are elastic structures which are found on the terminal parts of the fingers (fig 22). A nail has a root, the exposed portion or the body, and the free edge. The nails of the fingers grow faster than those of the toes. Hair is a modification of the epidermis. The palms, soles and the penis are devoid of hair. Hair consists of a root, shaft and the point (fig 21). The root is embedded in the hair follicle which is part

of the epidermis. Connected with the hair follicle are the erector pili. These are bundles of involuntary muscle fibers which elevate the hair. This is the ‘goose flesh’ that occurs in cold weather or at times of emotion and stress.

Fig 20 The skin showing the main layers of the epidermis.

Sebaceous glands (fig 21) are found in all areas and are abundant in the scalp, face, axillae and groin. In the palms and soles, they are minimal. The glands have ducts opening into the follicles. On the nose and the face the glands are large in size, with the eyes having the largest. Cell debris and fatty matter are secreted by these glands. Sweat glands are found all over the body in the subcutaneous tissue. They are most numerous in the palms, least in the neck. The glands open to the surface of the skin (fig 21) and secrete fluid. Aqueous and gaseous materials are excreted through the skin. If the fluid is decomposed by surface bacteria, the odor is unpleasant. Sweat production is stimulated by fever, fear and stress. Sweating is a means of regulating the temperature of the body in winter and summer. Functions of the skin The skin has multiple functions. It protects the underlying structures of the body from the external environment. Prevention of bacterial contamination is one of the main benefits. Temperature regulation is another important activity. The blood vessels of the skin dilate if the external temperature is raised, allowing excess heat from inside the body to dissipate. If the outside temperature decreases below a certain level, the blood flow in the skin reduces to preserve the core temperature. This ensures constancy of the internal environment. Exposure of skin to sunlight helps the formation of vitamin D, for which the precursor in the skin is 7-dehydrocholesterol. Exposure to sun

also makes for better blood flow in the skin. The skin, being one of the largest organs in the body, suffers a variety of lesions. These include disorders of pigmentation (vitiligo), freckles, moles, benign tumors, pre-malignant tumors, blistering diseases, infections, and bacterial and fungal infestations.

Fig 21 Main structures in the dermis.

Fig 22 The nail and related skin.

The Bony Skeleton Osteology is the detailed study of bones. I have explained in brief the basic skeletal structure of the human body (fig 23). Bone is composed of water, inorganic and organic material. There are two types of bone: compact and cancellous. Compact bone consists of a number of haversian canals containing blood and lymphatic vessels surrounded by compact layers of bone called lamellae. In between these are spaces known as lacunae containing the bone cells—osteocytes. The tubular arrangement is meant to provide greater strength. Cancellous bone has larger haversian canals and fewer lamellae, and red bone marrow is always present. Bones are covered by what is called periosteum. This gives attachment to muscles and tendons, and protects the bone from injury. The periosteum has blood vessels (figs 24, 25, 26). Bones can be classified as long (fig 27), short, flat (fig 28), irregular (fig 29) and sesamoid. Long bones such as the femur have a shaft (diaphysis) and two extremities. The centre is hollow and contains yellow bone marrow. A bone grows by extension of the diaphysis. There are centers for ossification in the bones where the bones harden. Irregular bones like the heel, flat bones like the skull, and sesamoid bone (which is not actually bone but ossification of a tendon often found in the thumb) contain red marrow. The arrangement of collagen in bones is either of a lamellar or nonlamellar pattern. There are two kinds of bone cells: osteoblasts, which develop into osteocytes which form new bone tissue; and osteoclasts, which cause resorption of bone to maintain shape and size. The body skeleton consists of two parts: the axial and the appendicular. The axial skeleton consists of the skull, the vertebral column, the sternum and the ribs. The appendicular consists of the bones of the upper and lower limbs—the clavicles and the scapulae, and the pelvis.

The skull The skull consists of a number of bones. It is actually made up of the frontal bone, the occipital bone, the two parietal bones, the two temporal bones, the sphenoid bone and the ethmoid bone (figs 30, 31).

The frontal bone forms the forehead and the eye cavities, the face and the brain. The parietal bone covers the brain on the sides and forms the roof of the skull. The temporal bones form the region of the so-called ‘temple’ on either side. This also extends behind the ears. The occipital bone forms the back of the skull. Its inner surface, which is concave, is occupied by the cerebellum and the cerebrum. The sphenoid bone forms the middle portion of the base of the skull and houses the pituitary gland on the inner surface. The ethmoid bone forms the orbital cavity, the nasal septum and the lateral parts of the nasal cavities. It houses the projections in the inner side of the lateral wall of the nose - the turbinates.

Fig 23 The bony skeleton.

Fig 24 A bone shaft in cross section reveals spongy internal structure.

Fig 25 Cross section of microscopic structure of bone.

Fig 26 Longitudinal section of microscopic structure of bone.

The sinuses are cavities in the front and inner portion of the skull. They are thought to give resonance to the voice. It is important to understand the anatomy of the sinuses. Each opens into a meatus or opening on the lateral wall of the nose, of which there are three. The lateral wall of the nose is that facing the septum on either side. A part of the ethmoidal sinuses open into the superior meatus. The frontal ethmoidal and maxillary sinuses within the respective bones have ducts that open into the lateral wall of the nose into the middle meatus. The sphenoidal sinus communicates with the recess between itself and the ethmoid. The duct from the eye-the naso-lacrimal duct that drains the tear secretion— opens into the inferior meatus. The superior, middle and inferior turbinates protect the different meatii. The upper part of the jaw is the maxilla, and the lower part is the mandible, which is movable. The skull protects the brain. The eyeballs and associated structures are also safeguarded. The ear is protected by the temporal bone. The teeth are embedded in the lower and upper jaws. The jaws are moved by the muscles of mastication.

The vertebral column The vertebral column (fig 32) is made up of 33 vertebrae, held together by the inter-vertebral ligaments. The inter-vertebral discs between the vertebral bodies are found. The vertebral column consists of (i) seven cervical; (ii) twelve thoracic; (iii) five lumbar; (iv) five sacral; and (v) five coccygeal vertebrae. The cervical region has the greatest range of movement. The column has a concavity on the rear aspect. This is the normal shape. Any alteration in this leads to degenerative joint disease. Injury also predisposes to similar changes. The skull is situated on the first cervical bone. The second cervical vertebra provides the pivot for the first and for the head. These bones are smaller than the thoracic and lumbar, but can withstand strong loads (fig 33).

Fig 27 A mature long bone, longitudinal section.

Fig 28 Irregular bone.

Fig 29 Flat bone.

Fig 30 The bones of the face (anterior view).

Fig 31 The bones of the skull and their joints or sutures.

The thoracic has a convexity on the rear aspect. The bones are bigger. This protects the contents of the thoracic cage (fig 34). The lumbar are the biggest in size; this area of the spine has a concavity on the rear aspect. Strong loads are borne by these bones (fig 35). The fifth lumbar articulates with the sacrum. This junction is important for spinal stability. The sacrum and coccygeal form fused entities and complete the framework (fig 36).

Fig 32 Lateral view of the vertebral column.

The functions of the vertebral column include enclosing the spinal cord and the emerging spinal nerves (fig 37), articulation of the ribs in the thoracic cage allowing respiration, and providing the basic framework of the body. Movements are determined by the shape of the column.

Figs 33, 34, 35 A cervical vertebra (left); a thoracic vertebra (centre); a lumbar vertebra (right). All viewed from above.

The thoracic cage is formed by 12 vertebrae and 12 pairs of ribs and the sternum or breast bone. These form the framework for respiratory movements. They form the connections between the upper limbs and the axial skeleton. They cover the diaphragm which separates the thoracic and abdominal contents. They assist in respiration. The sacrum, along with the pelvic cavity, encloses the pelvic organs.

Fig 36 The sacrum and coccyx.

The appendicular skeleton This includes the upper and lower limbs and the pelvis. The bones of the upper limbs are the humerus and the scapula, the forearm includes the radius and ulna, and the wrist has eight bones very small in size, known as the carpals. The metacarpals form the palms and the phalanges form the fingers. The thumb has only three bones.

Fig 37 Lower cervical vertebra separated to show the spinal cord and spinal nerves emerging through the intervertebral foramina.

Fig 38 The thoracic cavity.

Fig 39 Organs occupying the anterior part of the abdominal cavity.

The pelvis on each side is made up of a single large bone the os innominatum or ‘nameless’ bone. This large, irregular bone connects the lower limb to the trunk. This forms the prominent curve of the hip in the female. The flare of the two bones is wider (than in a male) to allow childbirth. The three parts of the hip bone are the ilium, the ischium and the pubis. The pelvic bone is larger than the thoracic and cranial bones. It is bound behind by the sacrum and coccyx and on the other sides by the innominatum. The pelvis is an important junction between the upper and lower parts of the body. The fetus is protected by the pelvic cavity in the early stages of pregnancy. The bones of the lower limbs include the biggest and strongest bone in the body— the thigh bone or the femur—the tibia and fibula forming the bones of the leg, and the ankle bones. These consist of seven bones and form the tarsus. The heel bone is known as the calcaneum. This bears the considerable weight of the body when in the erect position. The others in the foot are the metatarsals and the phalanges. The appendicular skeleton protects the nerves and blood vessels coursing along the body in various directions. It gives the framework to the body and allows movement in various directions.

The cavities of the body The various organs of the body are contained in the various cavities described.

Fig 40 Organs occupying the posterior part of the abdominal cavity.

The cranial cavity consists of seven bones in all. This encloses the brain and important nerves and arteries. The thoracic cavity (fig 38) is bounded by the sternum and the ribs in the front, the vertebral column at the back, the diaphragm below and the neck above. The main contents here are the heart, lungs, blood vessels, lymph nodes, trachea and esophagus. The space between the two lungs is known as the mediastinum. The largest in the body, the abdominal cavity (figs 39, 40) is covered by the diaphragm above, the abdominal muscles in front, the spinal column at the back, and is continuous with the pelvic cavity below. The contents include the stomach, liver, spleen, small and large intestines, pancreas, kidneys, the adrenals, important blood vessels and nerves, and lymph nodes. The pelvic cavity is covered behind by the sacrum, on the sides by the innominate bone, and the muscles of the pelvic floor below. The contents include the uterus, bladder, prostate, the seminal

vesicles, rectum, anus and colon. The different parts of the skeleton are named in the diagram (fig 23). The skeleton, though forming a tough framework for the body, is prone to disease. This includes hereditary disorders like Osteogenesis Imperfecta (brittle bones), infections like Osteomyelitis, fractures due to trauma or due to infections and tumors, nutritional diseases like rickets, damage secondary to renal malfunction, benign and malignant tumors.

Joints A joint is the site of articulation of two or more bones, held in position by strong ligaments and muscles. Movement is not implicit in defining a joint as there are many fixed joints. The joints in our body can be classified as fibrous, cartilaginous and synovial.

Fibrous joints These are sutures as in the skull or the cheek bones (maxillary bones); and syndesmoses, where the bony surfaces are united by an interosseous ligament (for example, the joint between the tibia and fibula in the lower end of the leg). A slight amount of movement is possible (fig 41).

Cartilaginous joints These are joints between vertebral bodies, or the pubic bones. The bones are covered with hyaline cartilage (fig 42).

Synovial joints Here the ends of the bones are covered by articular cartilage and there are accessory ligaments strengthening the joint. The inner surfaces secrete synovial fluid for lubrication and free movement. These joints can be: a. intercarpal joints (between wrist bones) with gliding movement; b. hinge joints (knee and elbow), where movement occurs around axes; c. pivot joints (second cervical vertebra with the atlas); d. condyloid joint (wrist); e. saddle joint (the thumb where opposing surfaces are concavoconvex); f. ball and socket (hip and shoulder).

Fig 41 A fibrous or fixed joint (eg: the sutures of the skull).

Fig 42 A cartilaginous or slightly movable joint (eg: between the bodies of the vertebrae).

The joints of the neck, i.e. the vertebral joints, have discs between the vertebrae. These discs cushion the joints and permit comfortable movement. These joints are prone to degenerative changes like spondylosis, arthritis and trauma. The movements of the cervical column include flexion, extension, lateral rotation, lateral flexion and circumduction. The blood supply is through the carotid arteries and the nerve supply is from the cervical nerves. The shoulder joint (fig 43) is a ball and socket type. The head articulates with the cavity in the scapula known as the glenoid cavity. It is lined with cartilage (known as the glenoidal labrum) and synovial lining. The ligaments are named in the illustration. The shoulder joints are fully mobile and are yet prone to affliction. In diabetic patients, the joint often gets ‘frozen’ (peri-arthritis). This means there is restriction of some of the movements. This happens even in non-diabetics. The shoulder is also one of the most frequently dislocated joints because of its greater range of intrinsic mobility. The movements of the shoulder joint include flexion, extension, internal and external rotation, abduction and adduction, and circumduction. The blood supply is from the axillary artery and the nerve supply from the axillary nerve and brachial plexus.

Fig 43 The shoulder joint (section viewed from the front).

Fig 44 Section of the elbow joint, partly flexed, viewed from the side.

Fig 45 Section of the wrist and distal radioulnar joints (anterior view).

Fig 46 Carpal tunnel, synovial sheaths and tendons of the wrist and hand.

The elbow joint (fig 44) is fairly stable. Ligaments on the front, sides and back strengthen the joint. Being a hinge joint, it is more difficult to restore mobility if it is diseased. The different parts are labeled in the illustration. The movements include flexion and extension, and a slight corkscrew movement. The blood supply is from the brachial artery, and the nerve supply from the radial and musculo-cutaneous nerves. The wrist (fig 45) is one of the most versatile joints. The ligaments cover all sides to provide stability with movement. It allows a wide variety of skills like writing, using musical instruments, and other dexterous hand work. It is traumatized quite easily due to a variety of reasons, the principle one being easy mobility. The movements include flexion and extension, abduction and adduction, and limited rotation. The blood supply is from the radial and ulnar arteries, the nerve supply from the median nerve. The flexor tendons of the wrist and fingers pass through a strong band of tissue on the

front of the wrist bones. This is the carpal tunnel (fig 46). This passage is narrow and the tendons are prone to becoming inflamed—the carpal tunnel syndrome. This can happen in arthritic disorders, notably rheumatoid, and in other conditions like posttraumatic, occupational—excessive computer usage, riding the scooter and in hypothyroidism where the tunnel gets narrow due to tissue infiltration. The joints of the fingers and thumb are equally versatile. The thumb has a larger area of representation in the brain than many other organs even though it is anatomically small. Finger movements include flexion and extension, abduction and adduction, and, for the thumb, opposition by which it can reach all the other fingers. This is unique to the human species. Fractures of the fingers are common during sporting events.

Fig 47 Section of hip joint (anterior view).

Fig 48 Supporting ligaments of hip joint.

Fig 49 Head of femur and acetabulum separated to show acetabular labrum and ligament of head of femur.

The hip joint (figs 47, 48, 49) is the strongest in the body. It has a head, a neck and a shaft. The head is lodged in a cavity known as the acetabulum. It is surrounded by powerful muscles and three strong ligaments—the iliofemoral, the pubofemoral and the ischiofemoral and hence, dislocation is not very common. The cavity is lined with thick cartilage known as acetabular labrum. The hip joint is very stable, anchored to the cavity by a ligament known as the ligament of the head of the femur. Being a weight-bearing joint, it is highly prone to degeneration. The movements include flexion and extension, abduction and adduction, internal and external rotation, and circumduction. The blood supply is from the internal iliac arteries and the nerves from the femoral nerve, a branch of the lumbar plexus. The knee joint (fig 50) is a hinge joint and has two large cartilages between the femur (the thigh bone) and the tibia (the shin bone). These are the semilunar cartilages (menisci). It has two collateral ligaments on the sides for stability and two ligaments, known as the cruciate ligaments, inside the joint, that prevent excessive forward or backward slide. The semilunar cartilages serve to cushion the movements and act as powerful shock absorbers during impact. There are bags filled with fluid called bursae that lubricate the movements of tendons on bone, and the patella on the skin. All cartilage is avascular and cannot regenerate. Re-growth is in the nature of fibrous tissue. Tears in the cartilages of the knee are very common, and they can easily be managed in most cases without surgery. The knee is most commonly prone to osteoarthritis. In rheumatoid arthritis, the entire architecture of the joint is inflamed. The movements of the joint include flexion and extension, internal and external rotation. The blood supply is from the popliteal and femoral arteries, and the nerves from the femoral, with the obturator nerve from the lumbar plexus.

Fig 50 The knee joint: superior surface of the tibia.

The ankle joint (figs 51, 52) is a hinge joint. This has a big bone, the heel, known as the calcaneum. There are four important ligaments for stabilization of the joint. They are the deltoid, anterior, posterior and lateral ligaments. This joint has an arch on the under surface which serves for proper weight transfer from the upper body. The arch should be neither excessive nor minimal.

Fig 51 Section of left ankle joint (viewed from the front).

Fig 52 Supporting ligaments of left ankle joint (medial view).

In a flat foot, there may be no arch at all (varying degrees exist). The movements include flexion and extension, inversion and eversion. The blood supply is from the tibial artery and the nerve supply from the tibial nerves. The nerves that run on the sole to innervate the muscles that flex the toes can get pressurized under the foot bones. This makes walking painful. The fat pad under the heel can become worn out due to many causes— dancing, excessive jogging or walking and asymmetrical weight distribution when standing. The situation progresses to inflammation of the tissues of the sole, and the friction on the heel bone leads to a spur formation—the calcaneal spur. The joints of the spinal column are unique and versatile. They are capable of a variety of movements, especially during yoga practice. There are 33 spinal vertebrae and up to the fifth lumbar vertebrae there are intervening discs which act as shock absorbers. They also help in the biomechanics of the spine for its various movements. The discs have an outer tough material and an inner jelly-like pulp. They have no blood supply and derive their nutrition from the surrounding tissues by the principle of diffusion. They degenerate with age, but not if the spine is exercised regularly. The most common problem is a slipped or a prolapsed disc, where the disc is forced out of position by ill-placed mechanical forces. The outer tough material breaks and the pulp is extruded. This pressurizes the adjacent spinal nerves.

The movements of the spine include flexion and extension, lateral flexion and lateral rotation along its entire length. The degree of movement varies from segment to segment. Adjacent blood vessels and veins serve the column along its entire length. The joints are no exception to disease states. Degenerative conditions like osteoarthritis, inflammatory conditions like rheumatoid infectious arthritis, metabolic arthritis like gout, and trauma are some of the afflictions.

Muscles Muscles help movement. They tone up the joint and because the joint moves, the muscles are also toned up. Tone is nothing but the resting tension in a muscle. It is a balance between rigidity and flexibility. Even in sleep there is some tone in the muscles, but none in a state of unconsciousness. Muscles have a contractile apparatus which helps initiate the process of excitation and contraction at the cellular level. Calcium is important for this process. There are three different types of muscle in the body: striated muscle, cardiac muscle and smooth muscle.

Striated muscle This includes muscles associated with the skeletal system. They are made up of fibres arranged in bundles (fig 53). All are individually wrapped in tissue. Most skeletal muscles begin and end in tendons. The fibres are arranged parallel so that the force of contraction is additive. Each muscle fibre is a single cell, long and cylindrical in shape. The fibres are made of fibrils and the latter of filaments which are the contractile units of the muscles. These contain the proteins, actin, myosin, troponin and tropomyosin (fig 54).

Fig 53 A striated muscle fibre, and a bundle of striated muscle fibres with connective tissue.

Fig 54 Arrangement of actin, tropomyosin and the three subunits of troponin (I, C, T), represented diagrammatically.

Electron microscopy divides the muscle fibre into several distinct functional areas. The cross striations on the muscles are due to differences in refractive indices of the different parts of the fibres. The striations are due to the presence of thick and thin filaments (fig 55). The thick filaments form the A band and the thin, the I band. The I band is divided by the Z line. The area between two Z lines is a sarcomere. The thick filaments are myosin and the thin, actin. Myosin is arranged on either side of the centre of the sarcomere. In the A band is the H line and the M line is inside this. The H line is the area where the muscle is relaxed (fig 55). Each thin filament contains 300 to 400 actin molecules and 40 to 60 tropomyosin molecules. Troponin molecules are located along the tropomyosin molecules. There are different types of troponin. The I variety inhibits the reaction of actin with myosin while the T kind binds troponin to tropomyosin, and the C kind contains binding sites for calcium. The muscle fibrils are surrounded by saccules, vesicles and tubules. This is the sarcotubular system, which is made up of a T system and a sarcoplasmic reticulum. The T system is a network of tubules in continuity with the membrane of the muscle fibre. The reticulum forms a curtain around the fibrils. The function of the T system is transmission of the action potential from the cell membrane to all the fibrils in the muscle. The electrical events are similar to those in a nerve. There is a resting membrane potential of skeletal muscle to the level of -90 mv. As the axon supplying a skeletal muscle approaches the termination, it loses its myelin sheath and divides into a number of buttons. These contain the transmitter, acetylcholine. The buttons fit into the ‘end plate’ of the muscle where it is thickened for this purpose. The entire junction is the myoneural junction.

Fig 55 Diagram of electron micrograph of human gastrocnemius muscle.

To summarise, in a muscle contraction, the nerve current causes release of acetylcholine, which binds to specific receptors. The electrical potential reaches the fibrils and the wave of depolarisation spreads in the T system. Calcium is released from the sarcoplasmic reticulum. This binds to the C kind of troponin.

Fig 56 Muscle contraction and relaxation. Calcium ions (shown as black dots) are stored in the cisterns of the sarcoplasmic reticulum. The action potential spreads via the transverse tubules and releases Ca2+. The thin filaments (thin lines) slide on the thick filaments and the Z lines move closer together. Ca2+ is then pumped into the sarcoplasmic reticulum and the muscle relaxes.

In a resting muscle, troponin I (a kind of protein) is bound tightly to actin and tropomyosin covers the binding sites between actin and myosin. So actin myosin binding is inhibited. When calcium binds to troponin C, the troponin-actin bond weakens; also, tropomyosin moves away, allowing actin to bind with myosin. Muscle contraction thus occurs by formation of cross-bridges between actin and myosin (fig 56). After the event is over, calcium is pumped back into the reticulum and the interaction between actin and myosin is stopped (fig 54). I have dealt with this in detail as it is the basis of all voluntary movements in our body. There are two types of contraction, fast and slow. Muscle fibres are trained thus. This depends upon the purpose of usage. Fast fibres use a lot of oxygen. Their function is to reach a high state of workout in a short period, in contrast to slow fibres which are long lasting. There are also two types of mechanical contractions — isotonic, where the muscle length actively shortens and isometric, where the total muscle length is still the same even during contraction. There are some instances when the same muscle can be used, simultaneously, to react with both mechanisms during a single movement. This happens in the practice of yoga.

The innervation of nerves to a muscle is by a mixed nerve, i.e., both motor and sensory. The blood supply is from the adjacent arteries and the fibres ramify into the substance of the muscle. The veins and lymphatics are in a similar arrangement. The attachment of the muscle to the tendon is very important. This serves to transmit the force to adjacent structures. Most skeletal muscles begin and end in tendons. Muscles have visco-elastic properties. Environmental temperatures affect this property. In cold conditions the muscle is stiffer and in tropical conditions the tissues are soft. Stretching of muscles causes neuro-muscular relaxation. This improves the blood supply, as the walls of the arteries are more relaxed during the stretch because of the fall in the sympathetic tone that controls the size of the vessel.

Cardiac muscle This (fig 57) also contains actin and myosin. It is similar to skeletal muscle in most of its structure and electromechanical properties. The only difference is that, after a contraction is over, skeletal muscle can still be stimulated, while cardiac muscle is totally resistant to stimulation as it has a refractory period which is absolute. The force of contraction of the heart is increased by adrenaline and noradrenaline. The mammalian heart has abundant blood supply and facilities for storing a higher content of oxygen in the cells. The specialised pacemaker tissue in the heart sets the rate of its beats. The heart can continue beating even after all the nerves to it are cut, because of the pacemaker.

Fig 57 Cardiac muscle fibres.

Fig 58 Smooth muscle fibres.

Fig 59 Main muscles of the face, head and neck (right side).

Smooth muscle This (fig 58) is microscopically different from the preceding types, though the units of actin and myosin are present. There are two types of smooth muscle, depending on their anatomical construction - visceral smooth muscle and multi-unit smooth muscle.

Fig 60 Main muscles which move the joints of the upper limb (left: anterior view; right: posterior view).

Visceral smooth muscle shows irregular contractions independent of its nerve supply. It is continuously active. The muscle also has plastic properties. The nerve supply is dual and is from the autonomic nervous system. Multi-unit smooth muscle shows discrete contractions. It is also sensitive to circulating chemicals of the autonomous nervous system. Figures 59 to 65 provide a pictorial review of the various important skeletal muscles. Their functions are listed in the table on pages 212-213.

Fig 61 Main muscles of the back.

Tendons Tendons are a part of muscles and serve to attach muscles to bone. They are made of collagen and are very strong but flexible. They have their blood supply from arterioles and nerve supply from sensory nerves. Muscle movement may be of various types: single, repetitive, or continuous; with rest or without; etc. The metabolism of the cells varies according to the demand. The length of the muscle may be shortened or constant, depending on the type of movement. When a muscle is stretched, there is resistance to the stretching, but if the stretch is steady and is maintained for a period of time, sudden relaxation occurs. There are some muscles which are active all the time. These are postural muscles like those of the spine. There has to be coordination between the muscle flexing a joint and that stretching the joint, otherwise the joint will be pulled to one side. Muscle movement may be in any plane: horizontal, vertical, lateral. Movement of a muscle improves the blood supply to the bone and the marrow. It also improves its own nutrition. Better muscle functioning means better venous return. The bones do not become osteoporotic if the muscles are used healthily. Movements of muscles produce indentations on the

bones, which help excellent bone remodelling. Muscles maintain their elastic properties if properly used. Just as the skeletal muscle can be toned, the cardiac and smooth muscles can also be toned up. The uterine muscle is one of the most responsive to training.

Fig 62 Muscles of the abdominal wall.

Its consistency remains healthy with active and regular exercise. The method by which all these are done is described in detail in the later chapters. Muscles can suffer many ailments - neurogenic ailments like myasthenia gravis, inflammatory conditions like polymyositis, genetic disorders like dystrophies, metabolic disorders, steroid-induced problems and those due to alcohol and drugs.

Fig 63 Cross-section of arrangement of the fascia of the muscles of the anterior abdominal wall.

Fig 64 Muscles of the pelvic floor.

Functions of Muscles Muscles of the head, face and neck Occipitofrontalis Levator palpebrae superioris Orbicularis oculi Buccinator Orbicularis oris Masseter Temporalis Pterygoid Sternocleidomastoid

raises eyebrows raises eyelid closes the eye and screws up the eye assists chewing and actions like blowing an instrument closes lips, shapes lips for whistling draws mandible to maxilla when chewing closes mouth, assists chewing closes mouth assists turning of neck from side to side

Muscles of the upper limbs Deltoid

abduction of arm, draws arm forward and upward, arm swinging when walking

Teres major Teres minor Pectoralis major Coracobrachialis Biceps Brachialis Triceps Pronator teres Brachioradialis Flexor carpi radialis Flexor carpi ulnaris Extensor carpi ulnaris Extensor carpi radialis longus and brevis Extensor digitorum Thenar muscle Hypothenar muscle

internal rotation of arm lateral rotation of arm elevation and flexion of arm, internal rotation of arm flexion of shoulder, adduction and circumduction flexion and supination of elbow main flexor of elbow extension of elbow pronates forearm flexes elbow joint flexes and abducts wrist joint flexes and adducts wrist joint extends and adducts the wrist extend and abduct the wrist extends wrist, extends finger joints helps draw the thumb at right angles to the palm, flexes thumb, approximates thumb wrinkles skin on the palm, makes palm hollow, abducts little finger, flexes little finger, brings little finger in opposition to thumb

Muscles of the lower limbs Iliacus Psoas Sartorius Quadriceps and vastii group Adductors Gluteus muscles Hamstrings Gastronemius Tibialis anterior Soleus

flexes hip joint flexes hip joint longest muscle in the body, flexes hip and knee extend the knee bring thigh close to centre of body extend hip joint and abduct it flex the knee flexes the knee and toes extends and everts the ankle flexes the foot and knee

Muscles of the back Trapezius Erector spinae Latissimus dorsi

elevates shoulder Refer section on low back pain for detailed explanation abducts, extends and assists internal rotation of arm, pulls trunk upward as in rope climbing

Muscles of the abdomen All these muscles maintain intra-abdominal pressure, assist lift of body from the supine position, assist defecation, flex the vertebral column and rotate the trunk to one side.

Fig 65 Main muscles of the lower limb (left: posterior view; right: anterior view).

The Cardiovascular System The heart is a four-chambered organ, with two upper and two lower chambers vertically partitioned into right and left sides. The upper chambers are the atria and the lower, the ventricles. The heart rests in the thoracic cavity, nestling between the lungs (fig 66). It is covered by three layers — an outer tissue layer (the pericardium), a middle muscular layer (the myocardium) and an inner layer (the endocardium) which is in anatomical continuity with the blood vessels.

Fig 66 Position of heart in the thorax.

Fig 67 Organs associated with the heart.

The muscle layer of the heart causes the contractions as a pump would, and its electrical component sets the rate and rhythm. Though medically the heart is classified as an involuntary organ, in reality it is semivoluntary. The heart has its blood supplied by two coronary arteries, very delicate in consistency. Two large blood vessels — the superior and inferior venae cavae — empty blood from the whole body into the right atrium. From here, the right ventricle receives the blood and pumps it into the lungs by the pulmonary arteries for oxygenation. The blood returns to the left side of the heart by the pulmonary veins into the left atrium, then into the left ventricle from where it is pumped to the rest of the body by the major artery — the aorta — and its branches. This is called a cardiac cycle, where there are two phases: a systolic or contractile phase, when the blood gets pushed to the rest of the body and to the lungs for purification, and a diastolic or relaxation phase, when the heart gets filled

up with blood (figs 67, 68, 69). The amount of blood ejected from the heart during systole is called stroke volume. The quantity of blood pumped out per unit time is called the cardiac output which, at rest, is 5 litres/minute. The heart has an intrinsic conducting system which regulates the heart rate (fig 70). The sino-atrial node, a mass of specialised nerve tissue in the right atrium, is the ‘pacemaker’ of the heart. This is connected with nerve fibres which ramify as a bundle into the rest of the heart. Yet, the nervous regulation of the cardiac cycle is also controlled by the sympathetic and parasympathetic nervous system. The function of the former is positive and the latter negative, as the table below will clearly show. Sympathetic

Para-sympathetic

Increases heart rate Increases power of contraction Dilatation of coronary arteries

Decreases heart rate Decreases power of contraction Constriction of coronary arteries Dilatation of blood flow in skin

Constriction of blood vessels in many organs, skin, etc.

Apart from this, the heart is also controlled by feedback from the mind and brain. Any change in psychological status causes changes in heart rate and rhythms. Many hormones, like growth hormone and thyroid hormone, affect the heart function.

The circulatory system The circulatory system can be divided into the systemic, the pulmonary and the portal (of the liver) circulation.

Systemic circulation This is the blood that is pumped to the rest of the body by the left ventricle. There is a major blood vessel known as the aorta arising from the left ventricle, which has a thoracic part and an abdominal part, and continues into the pelvis and lower limbs. Its branches are known by different names in different parts of the body (figs 71, 72). Let us learn a little about the anatomy of the arteries and veins (figs 73, 74). The arteries have a three-layer structure: the outer layer is the tunica adventitia, the middle the tunica media and the inner lining is the intima or the endothelium (fig 73). Arteries form links (anastomoses) with each other. In some areas of the body, like the eyes and the brain, no anastomoses exist. These are known as end arteries. The smallest arteries, called capillaries, have a single layer of endothelial cells through which water and small molecules can pass. Cellular nutrition is due to permeability of material through the capillaries into the tissue fluid and then through the tissue wall into the cell interior. This mechanism may be passive or active (fig 75). The pressure at the arterial end of the capillaries is around 35 mm mercury (hg) which forces nutrients into the cells. In the capillaries, it is around 25 mm hg. At the venous end of the capillaries it

is around 10 mm hg, which draws fluid into the vein. The capillaries end in sinusoids which are nothing but spaces from which the venules begin. Hence, capillaries have an arterial and a venous end.

Fig 68 Interior of the heart.

Fig 69 Coronary arteries.

Fig 70 Conducting system in the heart and the flow of blood through it.

The veins are thinner than the arteries. They have valves to prevent backflow of blood, especially in the legs (fig 74). The same three layers as the arteries are present. The smallest veins are called venules. The blood supply to the head and neck is by the carotid system of arteries, which has an internal and external part (fig 76). Between the bifurcation of the carotid into the two parts is a bulb of nerve fibre, known as the carotid sinus. This contains what are known as baroreceptors which control reflex changes in blood pressure. The branches of the carotid are known by the area of supply (fig 77).

Fig 71 Aorta and main arteries of the limbs.

Fig 72 Arch of the aorta and its branches.

Pulmonary circulation This consists of the two arteries which take blood from the right side of the heart to the lungs for purification: the large, low pressure distensible system of arteries, capillaries and veins in the tissue of the lungs; and the pulmonary vein which returns purified blood to the left side of the heart for distribution to the entire body.

Portal circulation This is the route by which the venous blood from the spleen, the pancreas and the abdominal part of the digestive system returns to the liver. Hepatic veins reach the inferior vena cava and thence the heart. Control of blood flow is very important during life. The body has the capacity to hold 25 litres by changes in regional blood flow. The mechanisms that control blood flow have various purposes like increasing or decreasing flow patterns according to the requirement of the body. The capillaries act as a medium for exchange of products between blood and tissues. The veins return de-oxygenated blood to the heart.

Fig 73 Structure of an artery (below) and a vein (above).

Fig 74 Interior of a vein. Left: valves and cusps; right: direction of flow of blood through a valve.

Fig 75 Diagram showing the beginning of a lymph capillary in the interstitial space.

Fig 76 Arteries forming the circulus arteriosus (circle of Willis) and its main branches to the brain.

The greatest resistance to blood flow occurs as the capillaries and its sphincters (valves) change, particularly during exercise. The blood vessels of the body are actually semi-voluntary. The blood flow to any part of the system can be increased or decreased by manipulation. The veins have a large flow of blood returning to the heart. They can be constricted by nervous stimulation or manual compression. Automatic regulation is the main factor that channels the blood to muscles and the heart during exercise. Neural and hormonal systems influence the circulatory system and its flow to a great extent, either positively or negatively. Changes in fluid volumes in the body (influenced by the kidneys) and better capillary perfusion are long term control mechanisms. The human body is essentially a system of circulation. It consists of a basic substrate, blood, which carries oxygen to various tissues driven by the central pump, the heart. A little knowledge about

regional circulation is essential before further analysis of the role of yoga in circulation.

Cerebral circulation The principal blood flow to the brain is via four arteries - two internal carotid and two vertebral arteries - which together supply the two cerebral hemispheres. The major arteries of the brain include the middle, anterior and posterior cerebral arteries. The branches of the carotid and vertebral arteries join at the base of the brain in a circular arrangement, known as the circle of Willis (fig 76). Cerebrospinal fluid (CSF) is formed from the blood by filtration and diffusion. It has various substances in it like sodium, potassium, calcium, magnesium, bicarbonate, glucose, uric acid, lactic acid and cholesterol. Over seventy years ago, it was demonstrated that when acidic dyes like trypan blue were injected into animals, all bodily tissues except those in the brain and spinal cord were stained blue. To explain this, a ‘blood brain barrier’ was postulated. This barrier maintains the constancy of the environment of the neurons which are dependent upon the concentration of calcium, potassium, magnesium and hydrogen ion. Therefore, even minor variations in these have far-reaching consequences. Another reason for this blood brain barrier is, probably, to protect the brain from endogenous toxins.

Fig 77 Main arteries of head and neck (left side).

Fig 78 Abdominal aorta and its branches.

Fig 79 Coeliac artery, its branches, and the inferior phrenic arteries.

The human brain weighs 1400 gm and the blood flow for the whole brain is 750 ml per minute. In subjects who are awake, the blood flow is greatest in the pre-motor and frontal region which is the area concerned with decoding and analysing afferent activity and intellectual functions. Epileptic areas have increased blood flow, while in senile brains there is greatly reduced blood flow. The cerebral blood vessels alone have the special capacity of ‘auto regulation’ of blood flow. If the pressure in the vessels increases, the surrounding CSF pressure also increases, preventing rupture of the arteries. The oxygen consumption is 49 ml per minute for the whole brain. The brain is extremely sensitive to lack of oxygen (hypoxia) and occlusion of blood supply for more than 10 seconds causes unconsciousness. Glucose is the main source of energy to the brain cells, though under conditions of starvation other substances may be used.

Coronary circulation The blood flow to the heart is by means of the two coronary arteries, right and left. The predominance may vary: right coronary dominance is seen in 50% of people, left coronary in 20% and equal contribution in 20% of people. The contraction period (systole) restricts blood flow in certain areas

of the heart. The major blood flow to the heart muscle is only when the muscle relaxes (diastole). The venous drainage of the heart is into the right atrium. Coronary flow is 250 ml per minute at rest.

Fig 80 Venae cavae and main veins of the limbs.

Pulmonary circulation The pulmonary vasculature is unique in that it receives a blood flow equal to that in all the organs of the body, viz, 5.5 litres at rest. The entire pulmonary system is a distensible low pressure system. The pulmonary arterial pressure is 24/9 mm hg and the mean pressure is 15 mm hg. The volume of blood in the pulmonary vessels is one litre, of which less than 100 ml is in the capillaries. When a normal individual lies down, the pulmonary volume increases by 400 ml. Local alterations in pulmonary blood flow are produced by changes in oxygen content. If there is occlusion of the bronchiole, the capillaries constrict, thereby shunting the blood away from the blocked area. Therefore, any rise in blood flow or opening up of minor airways means better oxygenisation.

Intestinal circulation The intestines are supplied with branches from the aorta. The blood flow to the lining of the intestine (mucosa) is greater than to the lumen, as it has to absorb food and perform metabolic activities. Thus, the blood flow in the small intestine doubles after a meal.

Hepatic circulation The liver receives 500 ml of blood per minute. It is a very vascular organ and has a major role in metabolism, including detoxification mechanisms. Its role is very important in cholesterol metabolism, glucose uptake and release, which will be discussed later.

Renal circulation In a resting adult, the kidneys receive 1.2 litres of blood per minute or 25% of the cardiac output. The blood flow is greater in the cortex than in the medulla. The oxygen consumption of the kidneys is 18 ml per minute. Regulation of fluid and electrolyte balance, excretion of various substances and regulation of blood pressure are some important functions of the kidneys. (figs 78, 79)

Fig 81 Section of a lymph node.

Fig 82 Some lymph nodes of the face and neck.

The blood flow to the pelvic organs and lower limbs is by branches of the aorta: the iliac arteries, the femoral, the popliteal, etc. Figure 71 will give an idea of the names and the area of flow.

Venous system The venous system is through two principal channels. The blood from the head and neck is returned to the heart by the superior vena cava (fig 80) and from the lower part of the body through the inferior vena cava. The inferior cava passes along the liver to reach the heart. The diagram illustrates the formation of the superior vena cava and gives the names of a few major veins in the body.

Lymphatic system The body tissues are bathed in a fluid known as lymph. The fluid is similar to plasma and, in addition, may carry particles like bacteria and cellular debris. This system has several components: lymph vessels, lymph nodes, spleen and the thymus gland. Lymph capillaries originate from tissues. (fig 75) The larger vessels are formed by the anastomosing of the smaller capillaries. The vessels have no ‘pump’, and the fluid is pushed up by rhythmic contractions influenced by the tone of the surrounding tissues, notably the muscles.

Lymph Nodes are spread throughout the body except the cranial cavity. They have a surrounding capsule, and afferent and efferent vessels that bring and remove fluid respectively through the substance of the node which is the trabeculae. The node is a regional filter. It helps localise infection, inflammation, spread of malignancy, etc. Common sites in the body are in the armpit (which gets affected in breast cancer), and the groin region (which enlarges in venereal infections). If the node is involved in an inflammatory process, it becomes tender - lymphadenitis (itis = inflammation). (figs 81, 82, 83) The lymph, along with bacteria, cellular debris and tumor cells, is filtered by tissues. Material not filtered in one node passes on to successive nodes. Activated T and B lymphocytes multiply in the nodes. Examples of lymphatic tissue are the tonsils, a collection of what is known as Peyer’s patches in the wall of the small intestine, and in the appendix. The spleen (fig 84) is part of what is known as the reticulo-endothelial system. Its functions are to destroy worn out red blood cells, white blood cells and foreign matter, and develop lymphocytes. The spleen provides a good quantity of the immune cells in the body.

Fig 83 Some lymph nodes of the upper limb.

The thymus gland (fig 85) lies in the root of the neck. Though this atrophies at puberty, it is an important component of the immune system in the growing years. The gland is important for activation of T lymphocytes. With age, the effectiveness of the T cell response to antigenic stimulation declines, but not if a person exercises regularly (see section on Exercise).

Blood pressure and pulse Blood pressure is that exerted by the force of blood ejecting from the left ventricle into the aorta, during contraction and relaxation. Hence, the names, systolic and diastolic pressure. The normal convention is to label the systolic over the diastolic, and this is around 120/80 mm of mercury. The pulse is the wave of pressure transmitted into the radial artery. It has characteristics like rate (normally around 70 to 80 beats per minute when healthy), rhythm (the interval between two beats),

volume, tension and character. All these vary in pathological conditions. For example, if the aorta is constricted, the blood flow into the peripheral area is less, resulting in a weak pulse. Both blood pressure and pulse are influenced by a variety of factors. Examples of conditions which increase blood pressure are renal failure, hyperthyroidism, adrenal gland tumors (which secrete chemicals that raise blood pressure) and fever. This is known as secondary hypertension, i.e., due to a particular cause. If no cause can be identified, it is labelled as essential hypertension, though this actually has subtler causes (see chapter on Essential Hypertension). The pulse rate can be increased by drugs, exercise, fever, rhythm disturbances, etc.

Fig 84 The spleen.

Conditions which decrease pressure and pulse rate include lassitude, typhoid fever, hypothyroidism, collapse, rhythm disturbances and haemorrhage. Pulse rate and blood pressure can malfunction independently of each other. If the blood volume is low, as in shock, the pulse might be rapid to make up for circulatory flow to the organs. Equally important factors, in altering the pressure and pulse to a higher or lower value, are the mind and age of the person. In old age, the arteries harden, elevating the pressure in the system.

Fig 85 Thymus gland and related structures in the adult.

The heart can suffer inflammation, infection and tumors. The pericardium can suffer the same lesions. The arterial system can undergo inflammation due to a number of causes. The veins can be prone to varicosities, infections and thrombosis. These days, the entire vascular system commonly suffers from an elevated sugar level, hypertension and high cholesterol level. The spleen is affected by inflammation, malignancy and enlargement due to a number of causes. Some of the common causes of enlagement include malaria, typhoid, cirrhosis and blood cancer.

The Haematological System ·Blood is the principal environment of the human body. Blood is a fluid of which plasma constitutes 55% and cells make up 45%. The pH of blood, the temperature and other various factors have to be maintained at a constant level of balance. This is called homeostasis. (fig 86)

Plasma contains a variety of materials Plasma proteins are albumin, which maintains proper osmotic pressure; and globulins, associated with immune functions, transport of hormones, etc. Hormones are thyroxine, growth hormone, etc. Immunoglobulins are of several types: IgG, IgA, IgM, IgD, IgE. Waste materials include urea and uric acid. Electrolytes are sodium, potassium, calcium and magnesium.

Fig 86 Blood cells through a microscope.

Nutrients include glucose, amino acids, fatty acids, vitamins and minerals. Gases are oxygen and carbon dioxide. Red blood corpuscles (RBC), white blood corpuscles (WBC) and platelets form the principal components of blood.

Red blood corpuscles These are biconcave discs which normally number around 4.8 million per cubic mm in a male and 4.5 million per cubic mm in a female. They are formed in the red bone marrow and the life of each disc in circulation is 120 days. The process of synthesis is known as erythropoiesis. This needs the presence of vitamin B12 and folic acid. Worn-out cells are destroyed principally in the spleen and in a few other areas. The growth and development of RBCs require iron, vitamin B12, folic acid and copper. Haemoglobin is a compound that is responsible for transport of oxygen in the form of oxyhemoglobin to the cells of the body. This is made up of haem (the iron moiety) and globin (the protein part). This compound also transports carbon dioxide from the cells to the lungs for excretion. Under conditions of poor oxygen availability, the kidneys release a hormone called erythropoietin, which increases RBC production by stimulating the bone marrow. RBCs are composed of water, haemoglobin, protein, fat and carbohydrates. They are deformable to a certain extent, and this is important in some clinical conditions.

White blood corpuscles The normal count of WBCs is 4000 to 11000 per cubic mm. They are the key mediators of immunological functions and inflammation. They are also the largest blood cells and are of three types: (i) granulocytes; (ii) monocytes; and (iii) lymphocytes. They arise from the red bone marrow and go through several processes before maturation and usage.

Granulocytes consist of neutrophils, eosinophils and basophils. The principal function of neutrophils is defence. They engulf and destroy foreign matter, producing cellular debris. They migrate into areas of infection, inflammation, burns, etc. Infection, smoking, use of certain drugs, leukemia, all cause an increase in the neutrophil count. In viral infections, they produce substances known as interferons, which inhibit viral replication inside cells. Eosinophils have similar functions. Their numbers are raised in a variety of clinical conditions, most commonly allergic, like asthma, hay fever, drug sensitivity and dermatological problems. Eosinophils contain enzymes and toxic molecules that are harmful to parasites. Basophils assist the general action of neutrophils, especially in the healing stage. They secrete a substance called histamine which causes vasodilatation and increased permeability of capillaries. Monocytes also work on defence areas and act to remove debris. Hence, they are called ‘scavenger cells’. The monocytes in tissues are known as macrophages and act in defence and scavenging work. They form part of the reticulo-endothelial system. They are found in the liver as Kupffer cells, microglia in the brain, alveolar macrophages in the lung, reticular cells in the lymph nodes and spleen, and osteoclasts in bone. Lymphocytes play a key role in immunological functions. They are of two types, T and B cells. They have to be activated to become immunocompetent. They then become effector cells that promote destruction of the antigen, and memory cells that remain in tissues and pass on the protective characteristic to subsequent generations of cells. The body is protected against autoactivation of antibodies, that is, there is a tolerance to self. If for any reason (and this is poorly understood) this tolerance breaks down, autoimmune diseases like rheumatoid arthritis and scleroderma (with its varied manifestations) occur. Normally self-reacting T cells are destroyed in the thymus. The T lymphocytes are used with memory cells in cell-mediated immunity against a variety of antigens like bacteria, fungi, drugs and cancer cells. They produce substances like interferons, which are bactericidal and anti-viral; lymphokines, which attract macrophages to the site; and toxins that destroy antigen. The B lymphocytes have on their surfaces various substances called immuno-globulins (Ig) which are of several types: IgG, A, M, D, E. These are basically made of proteins and are used during a variety of pathological states to protect the body.

Immunity A little knowledge about immunity is essential. Immunity is of two types: innate (or natural) and acquired (or adaptive). The term immunity is from the Latin immunitas: exemption from civic duties afforded to senators. It has long been recognised that those who had recovered from diseases like small pox were exempt from further attacks. Such immune individuals were often used in an epidemic to nurse patients. The basic differences between innate and acquired immunity are summarised below: Innate immunity

Acquired immunity

non-specific

specific

no change with repeat exposure

memory

mechanical barriers, natural flora

-

immunity mediated by proteins and substances known as lysozymes and complement

humoral immunity mediated by antibodies

cell-mediated type is by killer cells and phagocytes

by T cells

is

In a nutshell, B lymphocytes respond to antigens by differentiating into antibody-producing plasma cells, and T lymphocytes by cell-mediated immunity. Certain micro-organisms are inaccessible to the antibodies and it is here that T lymphocytes play a vital role. Factors determining innate immunity include age, hormonal differences, diseases like diabetes, hypothyroidism and adrenal dysfunction. Nutritional factors are vital to a healthy immune system. The mechanisms of innate immunity include mechanical barriers like the skin and mucous membranes which afford protection; this, however, is lost in burns. The skin is resistant because of the keratin which is indigestible by most micro-organisms and their toxins. The high concentration of salt is an inhibitory factor for invaders. The sebaceous secretions and sweat contain fungicidal and bactericidal substances. The feet, for example, are devoid of sebaceous secretions and this explains why feet are prone to fungal infections. Fungal infections of the skin, common in children, sometimes disappear at puberty when there is an increase in sebaceous gland activity. The mucus in the respiratory tract acts as a trap for inhaled particles. The cilia play their part. The flushing and washing action of tears prevents stagnation of secretions which may lead to infections. The normal bacterial flora of the skin produce anti-bacterial substances. The number of organisms in the gut is around 1014 and that in the skin is around 1012. If organisms of one area move to areas which are foreign to them, infection can result. The classic example is that of urinary infection due to a catheter being inserted. The E. coli organism is normally resident in the gut and produces urinary infection if it moves to the bladder. Microbicidal substances are present in tissue and body fluids. This is the humoral defence mechanism. The substances include lysozymes which are proteins that break down the chemical defence of the wall of the bacteria. Basic polypeptides are the other substances which are bactericidal. Substances known as acute phase proteins like interleukin, C-reactive protein, etc., damage the cell wall of the invader. All these stimulate the host response. Interferons, of which there are several types, are a group of anti-viral agents. Some are produced by lymphocytes. They interfere with the genetic mechanisms of the virus and prevent progeny formation. Complement is a group of proteins present in low concentrations in normal serum (20 in number). They have to be activated. Complement plays a role in the destruction of antigen-antibody complexes. The activation of complement gives rise to a number of substances that can eliminate bacteria. Cell-mediated immunity (of innate immunity) is by two main types of cells: the natural killer cells and

the phagocytes which include the neutrophils and the macrophages. Natural killer cells recognize changes in virus infected cells and kill them. This is performed by lymphocytes. They are also a defence against cancer. Phagocytic cells contain digestive enzymes to degrade ingested material and are a link between the innate and acquired immune mechanisms. These cells can process the foreign body and stimulate the development of lymphocytes into effector cells to deal with the situation. The second line of defence is acquired immunity. Here also there are two forms: humoral and cellmediated. Humoral immunity is by production of antibodies or immunoglobulins. These are produced by plasma cells which have developed from B cells. The cells combine with the antigen and have consequences like damage, subsequent digestion, or breakdown by complement. Whether the foreign body is harmful or not, antibody response occurs. Humoral immunity is mediated by antibodies or immunoglobulins from B cells. T cells provide growth factors for this process. Hence, there is a lot of interdependency. Cell-mediated immunity is by T cells and is effective against intra-cellular organisms. This type of immunity is used if humoral mechanisms are inefficient. Antigen activated T lymphocytes produce lymphokines. These lymphokines themselves activate macrophages. These lymphokines, when biologically active, are known as cytokines. These have many properties: growth, differentiation, activation, cytotoxic cell activity, antiviral effect, attraction to site of infection, etc. The lymphoid system consists of lymphocytes and other cells which get stimulated with antigens. The T lymphocytes develop in the thymus and the B cells in the bone marrow. These areas are known as the primary lymphoid organs. The secondary organs are the spleen and lymph nodes and areas associated with mucosal lining: the tonsils and Peyer’s patches in the intestine. Many factors determine an effective immune system: age, blood group, race, nutritional status and mental stress, to name a few.

Platelets These are special cells responsible for the clotting process. The life span of a platelet is around eight to ten days. Cell age is the cause of destruction. The number of platelets is the same for both sexes: 250,000 per cubic mm. A reduction in count occurs during the menstrual cycle. If the platelet count is below a certain level, bleeding can occur. When the blood vessel wall is damaged, the platelets release fibrinogen, which is acted upon by another chemical called thrombin to form a thread-like mesh. This and the entrapped blood cells form the blood clot. The clot is later broken up by a number of enzymes. Disorders of blood affect different parts. Disorders of the RBC include anaemia due to a variety of causes. An excess of red blood cells is called polycythemia. Disorders of white blood cells include reduction in count (neutropenia), increase due to inflammatory proliferation of cells and other causes. Cancerous change includes the different types of leukemias which are disorders of the stem cells in the marrow. Disorders of lymphoid cells are lymphomas. Plasma cells are also affected by these

processes. The spleen is affected by inflammation, malignancy and enlargement due to a number of causes. Some of the common causes of enlargement include malaria, typhoid, cirrhosis and blood cancer.

The Respiratory System The respiratory system starts from the upper respiratory tract, i.e., nose, sinuses and throat, down to the lungs via the trachea. It is the passage to life and any ill health in this area creates many primary and related disorders.

Fig 87 The organs of respiration.

The organs of the respiratory system (fig 87) are: (i) the nose; (ii) the pharynx; (iii) the larynx; (iv) the trachea; (v) two bronchi, one for each lung; (vi) two lungs; (vii) the muscles of respiration — the intercostal muscles; and (viii) the diaphragm.

The nose The nose is the first entrance through which inspired air passes. The entrance is guarded by what are called the ala nasii. These can expand and contract. Here, the lining of the nose filters dust and moistens the inspired air. The nose is in communication with the frontal and maxillary sinuses and the sphenoidal and ethmoidal sinuses. The secretions of these cavities drain into the nose. The nose has a roof, a floor, a side wall and a septum in the middle and a wall behind formed by the pharynx (fig 88). The lining of the nose has a rich supply of blood and innervation from both the sympathetic and

parasympathetic nervous systems. The blood supply is from the internal and external carotid arteries.

Fig 88 Lateral wall of the right nasal cavity.

The secretion of mucus makes the lining sticky. The cilia or fine hair cells serve to push the mucus into the throat to be coughed out. The nose is the organ of smell. The olfactory nerve has fine nerve endings in the nasal lining which enter the nose through the roof of the nasal cavity. The nose is essential for smell and breathing and, if the mouth is used for respiration as in heavy athletic and strenuous situations, ill health can result as the proper purification of air is lost.

The pharynx This is semi-voluntary and has a lining of mucous tissue and muscle which help in swallowing. The sympathetic and parasympathetic systems supply the pharynx with nerve endings. The pharynx is involved with both respiratory and digestive systems. In the latter, it is continuous with the esophagus. The eustachian tube has openings in the pharynx, thus connecting the middle ear cavity with the mouth. Proper hearing depends on correct air pressure in the middle ear cavity. The blood supply is from the carotid arteries and venous drainage into facial veins.

Fig 89 Pathways of air from the nose to the larynx.

The larynx This is also referred to as the voice box. It is larger in the male, and forms the ‘Adam’s apple’. It is made up of several cartilages with both sympathetic and parasympathetic nerve supply. The blood supply is again from branches of the carotid arteries. The vocal cords are strong folds of mucous membrane, the proper movement of which produces the right volume, pitch and resonance of the voice. The larynx acts as the primary airway (fig 89) and, during swallowing, it moves up, preventing food from entering the esophagus (fig 90).

Fig 90 Interior of the larynx seen from above.

The trachea As a continuation of the larynx, the trachea is around 10 cm long. It is composed of 16 to 19 incomplete cartilages. There are three layers: an outer layer of fibrous and elastic tissue, a middle layer of cartilage, and an inner layer of ciliated columnar epithelium with mucus-secreting cells. Both sympathetic and parasympathetic nerves innervate it. The blood supply is from branches of the carotid arteries and venous drainage by other veins.

The bronchi The trachea divides into two major bronchi, the right being bigger than the left. The bronchi are like an inverted tree and of the same structure as the trachea; they divide into bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts and, finally, the alveoli (figs 91, 92). The larger airways conduct air into the lungs. The lining of mucous membrane and cilia trap dust and other foreign particles. The nervine innervation is by the two branches of the autonomous system and the arterial supply from the bronchial arteries. Between the trachea and the alveoli, the airways divide 23 times. The pattern of air flow in the airways is of two types, laminar and turbulent. The diameter of these passages is under autonomic control. Yet, their size can be altered at will during the practice of yoga. The presence of immune cells in the respiratory tract mediates defense functions.

The lungs There are two lungs in the thoracic cavity. The right lung has three lobes and the left has only two. The lungs have an investment called the pleura. This invests the lung closely and also lines the inner layer of the rib cage. The space between the two layers, known as the pleural space, is normally devoid of any air. A small amount of fluid, called the pleural fluid, lubricates the movement of the two layers of the pleura and facilitates free expansion and contraction of the lungs. The blood supply

is through the pulmonary arteries which form tiny networks around the alveoli which are the cells of the lungs (figs 92, 93). These continue into the pulmonary veins. The alveoli are lined by two types of cells, type 1 and type 2. A special chemical called surfactant reduces surface tension in the alveoli, especially in the new born, and facilitates expansion of the lung. Without this, the lungs cannot expand and the infant can die. Exchange of gases occur in the alveoli by passive and active transport (fig 94). Internal respiration is the method by which the cells derive the drawn in oxygen and excrete carbon dioxide.

Fig 91 The trachea and associated structures.

Fig 92 A lung lobule.

Fig 93 Capillary network surrounding the alveoli.

Fig 94 Diagram of interchange of gases in the alveoli and the blood capillaries.

Fig 95 The intercostal muscles and the bones of the thorax.

Control of respiration Nervine control The normal human being breathes at the rate of 14 to 18 breaths per minute. The ribs are moved up and down by 11 pairs of intercostal muscles (fig 95). The thoracic cavity is separated from the abdominal cavity by the diaphragm. This is a sheet of muscle attached at various points, forming a complete partition. The diaphragm moves up during exhalation and downwards during inhalation. These movements of the diaphragm massage the abdominal organ. This accounts for 75% of the change in intrathoracic volume during quiet breathing. Respiration involves two processes: external, that is, the intake of oxygen and internal, which is the exchange of gases between the cells and their medium. In quiet breathing, 500 ml of air enters and leaves the lungs. This is known as the tidal volume. The air inspired with a maximal effort, in addition to this, is the inspiratory reserve volume. That which is expelled after a maximum effort following passive expiration is the expiratory reserve volume. The quantity of air left after this expiratory effort is the residual volume. The space occupied by gases that do not take part in exchange is known as the ‘dead space’. The vital capacity is the greatest quantity of air that can be exhaled after a maximum inspiratory effort. The slow movement of blood through the capillaries of the lung allow enough time for exchange of gases (fig 97). Control of respiration is both voluntary and involuntary. The brain is

actively involved in controlling the respiratory rate. The cells of the lungs are stretch-sensitive and have nerve endings which control the expansion of the lungs by reflex action (fig 96). The respiratory movements are well coordinated between the brain and the lungs. When there is any emotional change in the mind, the breathing rate changes.

Fig 96 Some of the nerves involved in control of respiration.

Chemical control There are special receptors in the cartoid arteries, known as chemoreceptors, that adjust the respiratory rate according to the levels of the partial pressure of carbon dioxide and that of oxygen in the blood. This is done by sampling the blood for the quality and quantity of the gases.

Accessory control The muscles of the neck are called the accessory muscles of respiration. These are not normally used in quiet breathing. In forceful breathing, the visible contractions of these muscles can be appreciated. Other factors of non-chemical control are those from the pons, hypothalamus, pharynx, trachea and bronchi for sneezing and swallowing. The baroreceptors which regulate blood pressure, as the

chemoreceptors regulate respiration, also influence breathing.

Fig 97 Diagram of interchange of gases during internal respiration.

The respiratory system is therefore a very delicate mechanism which will function well if handled properly. Lesions of the respiratory tract include congenital anomalies like cysts, pulmonary vascular disease, COPD (chronic obstructive pulmonary disease), infections, occupational lung diseases like coal worker’s lung, allergic conditions, and benign and malignant tumors. The pleura can also be affected by fluid collection, inflammation, infection and tumors.

The Digestive System Man survives by what he eats. Today many live to eat. The discipline of regular food habits prevents many illnesses. Energy is not only physical but also mental. Most of us eat more than we normally need and this disturbs the delicate functioning of all systems in the body. Many common ailments like diabetes, hypertension, indigestion and dyspepsia result partly from improper eating habits — the wrong food at the wrong time. It is essential, as far as practically possible within one’s lifestyle, to keep to regular hours of eating every day. Eating late in the night or too early in the morning damages the sensitivity of the endocrine and the neural regulation of the digestive systems. Let us try to understand the anatomy and physiology of the digestive system.

Fig 98 Organs of the digestive system.

The various organs of the digestive system (fig 98) are: (i) the mouth; (ii) the salivary glands; (iii) the pharynx; (iv) the esophagus; (v) the stomach; (vi) the pancreas; (vii) the liver; (viii) the biliary tract; (ix) the small intestine; (x) the large intestine; (xi) the rectum; and (xii) the anal canal.

Fig 99 General plan of the alimentary canal.

Before we proceed further, it is important to describe briefly the linings of the alimentary tract (fig 99). These are: (i) an outer covering or adventitia; (ii) a muscle layer; (iii) a submucous layer; and (iv) the mucous membrane. All the abdominal organs are covered by a membrane called the peritoneum, which has two layers. One layer lines the organ itself and is known as the visceral peritoneum and the other — the parietal peritoneum — lines the cavity of the abdomen. The pattern of organ covering varies from organ to organ (fig 100). The muscle layer consists of involuntary muscle lining all the organs, with some exceptions. This layer helps in peristalsis and, in the stomach, in proper churning of food.

Fig 100 The peritoneum, its association with the abdominal organs of the digestive system and the pelvic organs (side view).

Under the smooth muscle layer is a layer of subcutaneous membrane. Here lies a plexus of nerves, blood vessels and lymphatics. The mucous membrane has three functions: absorptive, immunological and secretory. There are mucus secreting glands which lubricate and also prevent the enzymes from injuring the tissues. The digestive juices break down the food to simpler fractions. Other cells exert a local protective action against infections. Both the sympathetic and parasympathetic nervous systems innervate the alimentary tract. The latter causes the production of juices and inhibits muscular contraction, while the former antagonises these functions. The aorta supplies blood, while the venous blood ultimately empties into the heart through the inferior vena cava.

The mouth

This is the entrance to the digestive system. The lips are in front, the pharynx behind, the cheeks on the sides, the palate above and the tongue below. The lining of the oral cavity is by stratified squamous epithelium with mucus secreting glands. The palate is hard in front and soft behind. The uvula is a fold of muscle hanging from the soft palate. The tongue is attached to the floor of the mouth. It has a number of little projections on the surface, called papillae, containing the nerve endings of taste (the taste buds). There are several kinds of papillae (fig 101). The nerve supply is by the 12th cranial nerve to move the muscles; a separate nerve for pain and touch and temperature; and the facial and glossopharyngeal nerves for the sensation of taste. The tongue helps mastication, speech, swallowing and taste. The blood supply to the tongue is by the lingual artery. The teeth are embedded in the lower and upper jaws. Each tooth has a root, neck and crown (figs 102, 103). The functions of the teeth are obvious.

The salivary glands There are three pairs of salivary glands. Two parotid glands are situated above and behind the angle of the jaw; their ducts open into the mouth at the level of the second upper molar tooth. Two submandibular glands lie on either side of the lower jaw; their ducts open on either side of the tongue where it is attached to the floor of the mouth. Two sublingual glands lie on the submandibulars; they have numerous ducts in the mouth (fig 104). Saliva basically consists of water, salts, some enzymes, mucus and immune factors. All the glands are supplied by the sympathetic and parasympathetic nerves. Stimulation of the latter causes secretion and of the former, reduction of secretion. The blood supply is from the carotid artery branches and the venous drainage is into the jugular veins.

The pharynx This has three parts: nasal, oral and laryngeal. The lining is stratified squamous. There are muscles which help swallowing, to push food into the esophagus (fig 106).

The esophagus This is about 25 cm in length and 2.5 cm in diameter. It lies behind the trachea and heart, and descends through the diaphragm to join the stomach (fig 105). There is a muscular sphincter at the upper end of the gullet and one at the lower end where it joins the stomach. The upper has to relax to allow passage of food into the esophagus and the lower prevents reflux of gastric contents into the esophagus. The blood supply is from the esophageal arteries and the venous drainage into certain other parts of the portal circulation. Both parts of the autonomous system innervate the esophagus.

Fig 101 Structures in the mouth, including the papillae of the tongue.

Fig 102 The permanent teeth and jaw bones.

Fig 103 Section of a tooth.

Fig 104 Position of the salivary glands.

The esophagus has peristaltic actions that serve to push the food into the stomach. The pH of the lower end of the esophagus is alkaline. Reflux of food is prevented by the valve, the angulation of the stomach with the esophagus, and the tension at the lower sphincter.

Fig 105 Esophagus and associated structures.

Fig 106 Positions during swallowing of structures in the head and neck.

The stomach This organ has a cardiac and a pyloric orifice, with a muscular sphincter at each end named likewise (fig 107). It lies in close relation to several organs: the pancreas behind, the spleen on the left, the liver on the right and the intestines on the lower side. The stomach has several types of muscle fibres — longitudinal, circular and oblique (fig 108). This allows for the characteristic churning activity. The folds of mucus membrane when the organ is empty are called rugae. Digestion begins in the mouth with the action of the enzymes in the saliva. The food passes into the esophagus, and is propelled by peristalsis into the stomach. The size and shape of the stomach is variable. The food is churned here and mixed with gastric juices which consist of water, which liquefies food; acid, which kills bacteria and acidifies food; mineral salts; mucus; enzymes like

pepsin, for protein digestion; and the intrinsic factor, which helps absorption of vitamin B12. The mixture is pushed into the duodenum.

Fig 107 Longitudinal section of stomach.

Fig 108 Muscle fibres of the stomach wall.

Fig 109 The pancreas.

The stomach is a factory for churning and mixing food and for enzymatic digestion only. Absorption in the stomach is very limited. The blood supply is by the gastric arteries, venous drainage into the portal system, nerves by the sympathetic and parasympathetic, the latter by the vagus. Stimulation of the former reduces motility of the stomach and stimulation of the latter increases it.

The pancreas Situated in the abdominal cavity behind the stomach, this is both an exocrine and an endocrine gland (fig 109). The former secretes juices for digestion. There are four cell types in human beings. These are the A,B,D,F cells. The A cells secrete glucagon, the B cells insulin, the D cells a hormone called somatostatin, and the F cells a polypeptide. Insulin and glucagon regulate glucose metabolism. The alkaline pancreatic juice which consists of water, mineral salts and certain enzymes digests fats, protein and carbohydrates. The actions of insulin and glucagon are antagonistic to each other, and each has factors that stimulate or inhibit their release. Insulin reduces the blood sugar level in contrast to glucagon. The function of somatostatin is to inhibit the secretion of both insulin and glucagon. The polypeptide reduces the level of glycogen in the liver. The blood supply to the pancreas is by the aortic branches and the veins join the portal vein. The functions of the pancreas are discussed in the section on endocrine glands.

The liver

Weighing around 1200-1500 gm, the liver is the largest organ in the body. It has two lobes and under the right lobe is the gall bladder (fig 110). The right lobe of the liver is larger than the left. The liver is made up of lobules formed by cells called hepatocytes. The cells lining the sinusoids (incomplete blood vessels) are macrophages. Two hepatic ducts drain the bile from the liver. The liver is a highly vascular organ with a total arterial and venous flow of 1500 ml per minute. The liver is the last gate, after which the inferior vena cava returns with venous blood from the lower half of the body to the heart. It is capable of mobility of around 3cm during quiet breathing. The liver carries out a wide array of metabolic functions: Carbohydrate metabolism, with storage or release of glycogen from glucose. This is influenced powerfully by other hormones of the body, especially insulin. Protein metabolism: Synthesis of plasma proteins and their export into the blood is a major function. Some of the clotting factors are made in the liver from amino acids. It breaks down amino acids and forms the waste product, urea, which is excreted in the urine. Uric acid is formed from nucleoproteins of worn-out cells. Fat metabolism: Dietary fat is broken down into many fractions. One such fraction, triglycerides, is used by the liver for metabolic processes. New lipid molecules are also synthesised. Bile is formed from the cholesterol synthesised by the liver. Bilirubin (a pigment) is produced by the liver and bile salts and bile acids are also formed. Bile acids produced from cholesterol are converted in the large intestine to secondary bile acids by colonic bacteria. In the small intestine, acids help absorb fat molecules. Insufficient bile acid formation results in malabsorption of fat and vitamins like D and K.

Fig 110 Anterior view of the liver.

Vitamins like A, D, E, K, and B12 are stored in the liver. Many hormones are inactivated in the liver and excreted in the bile. The liver has enzymes which metabolize a variety of drugs and alcohol. This function is impaired in liver disease. The cells of the liver also have immunological functions like destroying foreign antigens and preventing undesirable immunological reactions. The blood supply to the liver is from the hepatic artery and hepatic veins remove blood. Nerve fibres are of both parts of the autonomous system.

The gall bladder This is a pear-shaped organ which stores bile. The liver produces 1 to 2 litres of bile every day, which is stored in the gall bladder. In response to food and hormonal secretions, bile is released from the sac. It leaves the bladder through the cystic duct to enter the duodenum. As discussed above, bile is very important for emulsification of fat. It is possible to live without the gall bladder though there might be problems of fat absorption. Bile is concentrated in the gall bladder, which acts as a reservoir, as mentioned. The bile excreted by the liver is alkaline and that of the gall bladder acidic. The blood supply is from the hepatic artery and the venous drainage is into the portal system.

Fig 111 The small and large intestines and their associated structures.

Fig 112 Diagram of absorption of nutrient materials.

The small intestine This organ is around 15 feet long. It is here that the complete absorption and digestion of food occurs. The duodenum and jejunum are all continuous with each other (fig 111). The pancreas opens a duct into the duodenum for its secretions. The digestion of food is due to the action of enzymes from various sources: pancreas, gall bladder and intestinal secretions. Proteins, fats and carbohydrates are broken down and assimilated. The surface area for the absorptive processes is large and in folds of mucous lining. The functions of the small intestine include onward movement of food, secretion of intestinal juices, digestion, protection against bacteria, secretion of hormones and absorption. The surface has villi for absorption of food (fig 112). The cells of the villi, the enterocytes, enclose lymphatic and blood vessels. Fat is absorbed through the lymphatic and the broken down food particles through the tiny blood vessels. Below the villi are intestinal glands which replace the lining of the villi from time to time and help complete the process of digestion. The blood supply is from the aorta and the veins drain into the portal system. The nerves are from the sympathetic and parasympathetic systems.

The large intestine This is around 5 feet long and divided into ascending, transverse and descending parts (fig 111). The

rectum follows and, finally, the anal canal.

Fig 113 Diagram showing autonomic nerve supply to the digestive system.

This canal has two sphincters, one of which is under voluntary control and the other is involuntary. The absorption of water and salts occur in the colon. There are a variety of colonic bacteria which have very important functions of removing toxic waste products, fermentation of carbohydrates and fatty acids, etc. These are very essential for a healthy gut environment. The large intestine also has peristaltic action, though less frequent than the small intestine. Once the waste matter reaches the rectum, the involuntary sphincter relaxes and after the voluntary is made to relax, defecation occurs. Arterial supply is from the branches of the aorta. Figure 113 is a diagram of the nerve supply of the digestive tract. Different parts of the digestive tract are affected by lesions due to a variety of causes. Congenital conditions, infections, inflammation, cancerous change, stress-related lesions like peptic ulcer and colitis are common to the upper and lower gastrointestinal tract. Esophagitis, gastritis, colitis, colon

cancer, gastric cancer, esophageal cancer, allergic conditions of the intestine like sprue (sensitivity to specific substances in wheat), malabsorptive syndromes as in parasitic conditions, bacterial overgrowth — the list of possible disease states in the digestive system is endless.

The Renal System The kidneys are bean-shaped organs, around 11 cm long, 6 cm wide and 3 cm thick. They lie on either side of the vertebral column, with the adrenal glands on top, the liver on the right and above, the diaphragm above and the spleen on the left (fig 114).

Fig 114 Anterior view of kidneys showing areas of contact with other structures.

The organ is covered by a capsule, and has two functional parts: the cortex or the outer, and the medulla or the inner part. The renal pelvis is that part of the kidney which receives urine formed by the organ. The pelvis is actually formed of what are called renal pyramids ending in papillae. Urine passes through calyces into the pelvis and then into the ureter (fig 115). The kidney has one million functional units called nephrons. The nephron is actually a closed tubule at one end, with what is called the collecting tubule at the other end. The closed end is called the glomerulus. The rest of the nephron has convoluted tubules (fig 116). Each glomerulus has an afferent and efferent arteriole. The blood and its products are filtered in the glomerulus. The walls of the glomerulus are lined with flattened epithelial cells. Renal arteries supply blood and renal veins join the inferior vena cava. The sympathetic and parasympathetic nervous systems innervate the kidneys.

Functions of the kidney The kidneys form urine which is excreted by the bladder. This helps maintain good homeostasis. Waste products of metabolism, especially proteins, are excreted and electrolyte balance and acid base balance maintained. The formation of urine occurs in three phases: filtration, selective reabsorption and secretion.

Fig 115 Longitudinal section of right kidney.

Fig 116 Diagram of a nephron with the glomerulus and glomerular capsule.

In filtration, a variety of substances like salts, water, hormones, urea, toxins and drugs are removed in the glomerulus as the blood passes through its wall. The purpose of selective reabsorption is to absorb constituents needed by the body; and to maintain electrolyte balance and the alkalinity of the blood. The third process, secretion, removes substances not needed by the body. The colour of the urine is amber due to certain bile pigments. The normal volume of urine is around 1500 ml in 24 hours, but this is dependent on a variety of factors. Water and sodium levels are regulated according to hormonal influences, and dietary and environmental conditions. The kidneys help maintain the acidity and alkalinity of blood.

The ureters These are long tubes about 25 to 30 cm in length, which help propel urine to the bladder. They function by peristaltic activity and open into the bladder at specific points.

The bladder This is a reservoir for urine. It lies in the pelvic cavity, behind the pubic bone. Blood supply to it is by branches of the iliac arteries from the aorta. The outer wall of the bladder is composed of loose connective tissue, blood vessels and nerves. The middle layer is smooth muscle. The inner lining is transitional epithelium (fig 117).

Fig 117 The ureters in relation to the kidneys and the bladder (section showing trigone).

The urethra The urethra is a canal for passage of urine to the exterior. The female urethra is 4 cm and the male around 20 cm long. There are two sphincters: internal (at the start of the urethra in the pelvic cavity) and external. The latter is under voluntary control. In an infant, 200 to 300 ml of urine is enough to cause emptying of the bladder. When the nervous system is mature, conscious inhibition of the bladder reflex occurs. The muscle of the bladder is called the detrusor. This is under parasympathetic control through the pelvic nerves. The smooth muscle of the bladder wall in the area between the opening of the ureters known as the trigone is under sympathetic control. The internal sphincter is also under sympathetic control. The external is under voluntary control. The adult bladder can accommodate around 400 ml without a rise in bladder

pressure. Above this, sensations of fullness are transmitted to the sacral part of the spinal cord which tries to initiate emptying; voluntary control prevents this. Micturition is initiated by removal of voluntary control.

Renal diseases The major renal diseases include renal failure due to a variety of causes: inflammatory, infectious, drug-induced, immunological, etc. Systemic diseases like diabetes hypertension can damage the nephron. Obstructions in the urinary tract like a stone in the ureters or bladder can affect the kidneys by back pressure, as emptying is interfered with. Renal arterial disease is another disorder. The bladder and urethra can be affected by infections, tumors, etc. Tumors of the kidney can be benign or malignant.

The Endocrine System There are seven endocrine glands in the body (fig 118). They pass their secretions directly into the blood stream, without ducts, and hence they are called ductless glands. These glands are: (i) the pituitary gland; (ii) the thyroid gland; (iii) the parathyroid glands; (iv) the adrenal gland; (v) the islets of Langerhans in the pancreas; (vi) the pineal gland; and (vii) the testes and ovaries. The last two are dealt with under the reproductive system.

The pituitary gland This is the kingpin of all the glands in the body. It lies in the skull in a special place called the pituitary fossa and has two lobes. The hypothalamus and pituitary are linked by numerous nerve pathways (fig 119). In general, the hypothalamus secretes releasing or inhibiting factors that regulate the pituitary in its release of appropriate hormones. This is controlled by a feedback mechanism. The blood supply is by the internal carotid artery. Venous drainage is into the jugular veins. The following hormones from the hypothalamus are stored in the posterior lobe of the pituitary. Their release is mediated by the hypothalamus. Antidiuretic hormone: This regulates water levels in the body in health and in a variety of diseased states. Oxytocin: This controls milk ejection during lactation and influences uterine contractions during labour. The hypothalamus releases factors which control other endocrine glands. The cells of the anterior part of the pituitary are of three types:

Acidophils These secrete growth hormone (GH) and prolactin. GH has very important functions in that it regulates proper skeletal growth, regulates protein synthesis, increases the level of blood glucose and breaks down fat cells. The release of growth hormone is influenced by a number of factors like stress, anger, worry, sleep and exercise. Prolactin is involved in initiating and maintaining lactation and has

an action on the breast after parturition. The act of suckling by the baby releases this hormone.

Fig 118 Positions of the endocrine glands in the body.

Fig 119 Parts of the pituitary gland and its relation to the hypothalamus.

Basophils These secrete hormonal regulators that affect the other endocrine glands. They are: (i) Thyroid stimulating hormone (TSH) which stimulates the thyroid gland to produce more hormone; (ii) Gonadotrophins, which act on the ovary and testes — follicle stimulating hormone (FSH) and luteinising hormone (LH). FSH and LH are the key mediators of the menstrual cycle; (iii) Adrenocorticotrophic hormone (ACTH), which stimulates release of cortisol and other steroid hormones from the adrenal cortex.

Chromophobes These contain secretory granules. The pituitary can fail — hypopituitarism — in all its parts and all other glands stimulated by it may fail secondary to this. Hormonal replacement is then needed. A tumor of the gland can cause over production of GH and gigantism can occur. All these diseases are amenable to treatment.

The thyroid gland This is situated in front of the trachea, with two lobes at the level of the 5th, 6th and 7th cervical vertebrae. It is a highly vascular gland. The raw material for synthesis of the hormones thyroxine (T3) and tri-iodothyronine (T4) is iodine. This is very rapidly used up by the gland. Blood supply is by the branches of the thyroid arteries and venous return is into the jugular veins (fig 120). Iodine is needed for formation of thyroxine. Thyroid hormones speed up the metabolic rate. They help normal maturation, growth and development. They also sensitise the heart and nervous system to alter their rate of functioning. Deficiency of T3 or T4 depresses all important functions in the body, particularly carbohydrate, fat and protein metabolism, while an excess causes overfunctioning. T3 or T4 can be raised or lowered in disease states. An enlargement of the thyroid gland is termed as goitre. This has many causes such as hypo- or hyper-functioning of the gland, malignancy, inflammation, etc. If the gland is hypo-functioning, the pituitary gland stimulates it to produce more hormone, and the gland enlarges in response to this stimulus. Overfunctioning of the thyroid is due to an auto malfunctioning located more often in the thyroid gland itself and the commonest presentation is termed as Grave’s disease. Both conditions are amenable to treatment.

Fig 120 The thyroid gland and associated structures.

The parathyroid glands These are four small glands, two embedded on the posterior aspect of each lobe of the thyroid gland (fig 121). There are two distinct types of cells — chief cells and oxyphil cells. The former secrete parathormone. This is a protein with a molecular weight of 9500. Its principal action is to mobilise calcium from the bones and increase the production of an active metabolite of Vitamin D. Hypofunctioning of this gland most commonly causes a condition known as tetany, where the fingers go into a cramp-like state. Excess of this hormone causes de-mineralisation of bones, loss of calcium in urine, and renal stones. Hyper-parathyroidism and hypo-parathyroidism have specific clinical manifestations each. It is important to mention here that certain cells known as the parafollicular cells of the thyroid secrete a hormone called calcitonin. This is a protein with a molecular weight of 3500. This hormone inhibits bone resorption and lowers plasma calcium. This is useful in some clinical conditions like Paget’s disease and osteoporosis.

Fig 121 The parathyroid glands and related structures (viewed from behind).

The adrenal glands Each gland, positioned above the right and left kidneys, is divided into two parts, the adrenal cortex and the adrenal medulla (fig 122). The adrenal cortex produces cortisol and corticosterone, aldosterone and sex hormones (androgens). Some of the functions of cortisol are regulation of carbohydrate metabolism; formation of glucose from protein, thus elevating blood sugar; absorption of sodium and water from the tubules of the kidney. An excess of cortisol or lack of it causes clear-cut clinical manifestations. Aldosterone controls water and electrolyte levels in the body. It also indirectly influences blood pressure. Androgens are important for muscle mass and protein build-up in males. They are positive in their effects.

Fig 122 The adrenal glands in relation to the kidneys and other structures.

The adrenal cortex may hypofunction — Addison’s disease. The patient suffers from lassitude, exhaustion, low blood pressure, vomiting, nausea, hypotension, etc. The cause may be in the pituitary or in the gland itself. The gland can overfunction — Cushing’s syndrome. The patient suffers high blood pressure, infections, obesity, hypertension, water retention, etc. The aldosterone secreting part can also malfunction — hyperaldosteronism or Conn’s syndrome. High blood pressure, retention of salt and water retention occur. The adrenal medulla is stimulated by the sympathetic nervous system. The principal hormones released are adrenaline and noradrenaline. Both these are very important for energy levels in the body. They cause conversion of glycogen to glucose and, at times of stress, give the necessary boost for cellular functioning. They increase the metabolic rate of the body, dilate the pupils, release glucose from the liver, raise oxygen consumption of the body. The blood supply is from the renal artery and the aorta. The veins are the adrenal veins. A common tumor of the medulla is known as pheochromocytoma, where excess production of catecholamines leads to headaches, elevated blood pressure, giddiness, exhaustion, etc. Prompt management is essential.

The islets of Langerhans These are special parts of the pancreas that have four types of cells. Two are very important: alpha

cells, which secrete the hormone glucagon which elevates blood sugar; and beta cells, which release insulin which maintains the blood sugar at a constant rate in conjunction with glucagon. Both these hormones balance their metabolic activities. The levels of these hormones are influenced by a variety of conditions like exercise, stress, emotion and infection. The principal function of the islets of Langerhans is the regulation of carbohydrate metabolism. This is by insulin and glucagon. The common and important malfunction of the gland is diabetes mellitus. Tumors can occur in the pancreas where the islet cells secrete excess insulin: insulinoma. This may be associated with other endocrine tumors elsewhere in the body. Tumors of the glucagonsecreting part are also known to occur.

The pineal gland This gland, whose functions are not yet fully understood, produces a hormone called melatonin. The gland calcifies in many individuals. In birds, this gland is responsible for their sense of direction which helps them migrate.

The Nervous System We live because of the energy in our nervous system. The very vital energy in the subtler layers of our body is nervine energy. In the ancient texts it is said that he who knows how to harness the inner energy reaches the source of all creation and nothing is impossible for him. This actually results in the incredible siddhis of the yogis. Let us understand the anatomy and working of the nervous system. It is useful to divide this system into three parts: (i) the central nervous system, with the brain and the spinal cord; (ii) the autonomous nervous system, comprising the sympathetic and parasympathetic systems; and (iii) the peripheral nervous system, which has 31 spinal nerves and 12 pairs of cranial nerves. The basic functional unit of the nervous system is called a neurone (fig 123), supported by special tissue called neuroglia. Each neurone has extensions called axons and dendrites. The axons are covered by a myelin sheath. This consists of Schwann cells. Some nerve fibres lack a sheath. At regular intervals are areas of exposed nerve tissue called nodes of Ranvier. The nerve impulses are like electrical charges. The axons transmit impulses away from a neurone while the dendrites work in a reverse manner. Many dendrites are interconnected. There is no anatomical continuity between nerve cells — this is known as a synapse (figs 124, 125) — but chemicals are secreted to transmit the electrical charges. It is believed that noradrenaline, gamma aminobutyric acid (GABA) and acetylcholine act as neuro-transmitters. Nerves may be sensory or motor. The former are responsible for sensations like touch, pain, temperature, maintenance of posture and equilibrium. In the skin, for example, these nerves lose their sheath and divide into fine branching filaments (fig 126). The nerve fibres reach up to the dermis only. Special senses serve the functions of smell, sight and taste.

Fig 123 A neurone.

The motor nerves originate in the brain, spinal cord or nerve plexuses. They cause contraction of skeletal muscle, glandular secretion, and contraction of the smooth muscle of the internal organs. These end in what are called motor end-plates in the muscle. Each muscle fibre is stimulated through a single motor plate, and one motor nerve has many end-plates. The group of muscle fibres and the motor end-plates are collectively referred to as a motor unit (fig 127). The strength of contraction of many motor units produces muscle action. Nerve tissue has the ability to respond to touch and to changes in the inner body such as chemical changes. It also has the ability to conduct impulses from one part of the brain to another, from muscles and joints to the brain, from the brain to organs with smooth muscle for contraction as in the intestine, and from the outside world to the brain through the special senses.

The central nervous system The cells known as neuroglia continue to proliferate throughout life. In the brain, the superficial parts are the grey matter, with the white matter deep in the brain. This is in contrast to the spinal cord structure where the situation is the reverse. The brain and spinal cord have discrete coverings from without called dura mater, arachnoid mater and pia mater. The first forms a lining in the inner surface of the skull. The last covers the brain closely with invested blood vessels. Between the arachnoid and pia mater is a space filled with cerebrospinal fluid (CSF), 720 ml of which is secreted every day. This fluid, which is continuously secreted, passes through the ventricle and enters the spinal cord through an opening in the roof of the 4th ventricle. It serves to act as a shock absorber, to maintain uniform pressure, and to help exchange nutrients and waste products.

Fig 124 Diagram of a synapse, indicating dendrites and axons.

Fig 125 Section of a synapse (enlarged).

Fig 126 Sensory nerve endings in the skin.

Fig 127 Longitudinal section of a motor unit.

The brain This is divided into (i) the cerebrum; (ii) the midbrain; (iii) the pons and medulla; and (iv) the cerebellum or hindbrain (figs 128, 129).

Fig 128 Parts of the central nervous system and the functional areas of the cerebrum.

Within the brain are four cavities known as ventricles. These are the two lateral ventricles, the third ventricle and the fourth ventricle which is continuous with the central canal of the spinal cord. The cerebral cortex has several lobes which are interconnected by masses of nervous tissue. The superficial layers of the cerebrum consist of nerve cells or grey matter, and the deeper layers of nerve fibres or white matter. The motor fibres for the body start from the cerebral cortex, originating in the frontal lobe. The internal capsule is the name given to the area of white matter containing the nerve fibres which pass to and from the cerebral cortex. It is a narrow area with the nerve fibres bundled up so closely together that, if the blood supply is affected in any way, all nerve fibres serving various functions can be affected. This is deep inside the brain (fig 130). We should understand the importance of this internal capsule area to enable us to study the chapter on

strokes later on. The fibres from the right half of the brain control the left half of the body as they cross over in their descent at the level of the medulla oblongata (crossed corticospinal tract in figure 130 which illustrates the left half of the brain controlling the right half of the body); but a few fibres control the same side. There are also nerve fibres connecting the cerebral cortex to the other parts of the brain. Among the many functions of the cortex, the chief are thought processes (frontal lobe), vision (occipital lobe), speech, hearing, recording bodily sensations and motor functions.

Fig 129 The cerebellum and its associated structures.

Fig 130 The internal capsule and its connections with the spinal cord.

Deep inside the cerebral hemispheres are buried the thalamus, hypothalamus and a structure known as the basal nuclei. The thalamus is the relay area for input from the skin, viscera and special senses. The hypothalamus has many important functions like regulating endocrine gland functions, hunger, thirst, body temperature, heart and blood vessel tone. The basal nuclei influences proper body movement. If this is damaged, movements become irregular, coarse and uncoordinated as in Parkinsonism. The midbrain and pons are relay stations for ascending and descending pathways, among other functions. The medulla oblongata has several important functions. It influences heart rate, respiratory rate, blood pressure, coughing, vomiting, sneezing and swallowing.

The cerebellum is concerned with voluntary movements, coordination, balance and posture. These functions are both involuntary and voluntary. Any damage to the cerebellum results in clumsy, jerky and uncoordinated movements, with an altered gait. The reticular formation is a bundle of nerve cells in the brain stem. Its principal action is arousal of the individual from a state of passivity. It also controls autonomic functions of organs, and balance and movement of muscles and joints. The entire brain and cerebellum can suffer a variety of pathological conditions like infections, inflammation, benign and malignant tumors, etc. One of the most malignant tumors of the brain is known as glioblastoma multiforme. Degenerative diseases like Alzheimer’s disease, hereditary degenerations affecting different parts of the brain, nutritional disorders, developmental malformations, and metabolic diseases are some of the other disorders affecting the system.

The spinal cord This extends from the medulla right up to the level of the first lumbar vertebra. It is about 45 cm long and has the same three coverings as the brain. The cord is the link between the brain and the rest of the body, except the cranial nerves. There are both ascending and descending pathways in the cord to receive and conduct impulses. At certain times, messages from the cord supersede those of the brain. There is a cervical enlargement, a lumbar enlargement, fissures and grooves, in front and behind, marking the length (fig 131). The principal functions of the spinal cord are both motor and sensory. It transmits sensations of touch, pain, temperature and proprioception. It co-ordinates muscle movement, using afferent and efferent pathways. Below the level of the first lumbar vertebra the dura mater and arachnoid mater continue externally. The cord internally narrows to a tip called the conus. From this a fine strand of tissue extends up to the level of the fifth sacral vertebra — the filum terminale (fig 132). Around this is a bundle of nerve roots known as the cauda equina. The blood supply to the cord is along its entire length, on both sides, from spinal arteries. A cross section of the spinal cord reveals that the centre is occupied by grey matter (in the form of an ‘H’), and the periphery by white matter. Different areas serve different functions (fig 133). Those that mediate fine touch, pressure, vibration, and stimulus from joints and muscles travel in the rear part of the cord, to reach the medulla and thence onto the hypothalamus. Those that mediate pain, temperature, touch, and deep pressure ascend in the front and sides of the cord but can cross over to the other side. Those that serve body movement arising from the motor area of the cerebral cortex descend in the front and sides of the spinal cord as the cortico-spinal tract, to end at various levels of the spinal cord. Secondary motor fibres reach the muscles from here. The spinal cord can suffer tumors, infections, degenerative conditions like motor neuron disease, nutritional diseases like B12 deficiency, hereditary damage to the cells, etc.

Fig 131 Layers of the spinal cord.

Fig 132 Section of the distal end of the vertebral canal.

The autonomous nervous system This has two divisions: the sympathetic and the parasympathetic. Though apparently involuntary, they can, by certain practices in yoga, be made semi-voluntary. The autonomous nervous system includes parts of the central and peripheral nervous systems.

Fig 133 A simplified diagram of the main tracts of the spinal cord; ascending tracts on the right side and descending tracts on the left.

The sympathetic system The sympathetic trunks consist of a series of ganglia connected by intervening cords extending from the base of the skull to the coccyx, one on each side of the body in front of the vertebral column; at the level of the coccyx the cords meet each other in a terminal unpaired ganglion. Each ganglionated cord may be traced into the cranial cavity. The ganglia of these cords are divided into a cervical part (3 pairs of ganglia), a dorsal part (12 ganglia), a lumbar part (4 ganglia), and a sacral part (4 to 5 ganglia). The cervical part consists of a superior, middle and inferior ganglia. The thoracic part is level with the thoracic spinal nerves, T1 to T12. The lumbar part is near the psoas muscle, and the sacral part in front of the sacrum. The whole arrangement is the thoraco-lumbar outflow. The superior cervical ganglia supply the vagus nerve, hypoglossal nerve, facial nerves, spinal cervical nerves, larynx, heart and pharynx. The middle ganglion supplies the heart, thyroid, trachea and esophagus. The inferior supplies the cervical and thoracic spinal nerves, the heart, the vagus nerve, branches to blood vessels, etc. Fibres also supply the upper limb through the spinal nerves. Those supplying the blood vessels are vasoconstrictor in nature. The dilator muscles of the pupil of the eye are also supplied from the cervical ganglia, and other branches go to the face and neck for controlling sudomotor functions. The thoracic part of the sympathetic trunk contains ganglia which correspond to the number of the thoracic spinal nerves. The ganglia nest near the head end of every rib, except the last three. The branches are in communication with the cardiac and pulmonary plexus, supply the trachea, esophagus, and aorta, and form what are known as the splanchnic nerves, which are three in number.

The lumbar part of the sympathetic trunk has four connected ganglia. The first three lumbar spinal nerves are in communication with this. The ganglia are in connection with the coeliac, aortic and hypogastric plexuses. The other branch is the vascular (to the blood vessels: aorta, iliac artery and femoral artery). The pelvic part of the sympathetic system is in front of the sacrum and, at a lower level, unite in front of the coccyx to form the ganglion impar. The spinal nerves at this level communicate with the sympathetic plexuses. Vascular branches go to the arteries in this area. The great plexuses of the sympathetic chain — the cardiac, the epigastric or solar and the hypogastric — supply branches to the viscera. From the solar plexus are derived a number of plexuses known as the renal, supra-renal, spermatic, diaphragmatic and the coeliac. From the coeliac are de-rived the gastric, hepatic and splenic plexuses. The other derivatives are the aortic and superior mesentric plexuses. The pelvic plexus is from the hypogastric (fig 134).

The parasympathetic system

Fig 134 The right sympathetic trunk and its connections with the thoracic, abdominal and pelvic plexuses.

There are two pathways in this system. The first arises either in the brain or in the spinal cord (cranio-sacral outflow), and the second starts in the ganglion or in the wall of the organ supplied. The cranial part includes supply from the oculomotor nerve, facial nerve, glossopharyngeal, accessory and vagus nerves. The last travels all the way down to the abdominal cavity in relation to several important structures (fig 135). On the way it supplies branches to the ear, larynx, heart, lungs, esophagus, gastric, coeliac, renal and hepatic areas. The sacral part includes the second, third and fourth sacral spinal nerves. The pelvic nerves supply the pelvic viscera. In the autonomic nervous system there are two stages in the efferent supply to the viscera. The first is known as the pre-ganglionic, where an axon reaches the ganglion from the spinal cord or cranial nerve nucleus; the other is the post-ganglionic, with the axon leaving the ganglia to the area supplied. In the sympathetic system, the pre-ganglionic fibres are from the spinal nerves in the thoracic and

lumbar areas. The post-ganglionic fibres are situated near the area supplied. In the parasympathetic system, the pre-ganglionic fibres start from the cranial or sacral nerves, and the postganglionic fibres may be in the wall of the organs themselves (see fig 113 in the chapter on the digestive system).

Fig 135 Position of the vagus nerve in the thorax (side view)

Functions of the autonomous nervous system

It can be seen that the functions of the parasympathetic system are energy conserving and the sympathetic system mobilises energy for body activity. Parasympathetic reactions are localised and sympathetic reactions are mass-responsed.

The peripheral nervous system This has 31 pairs of spinal nerves and 12 pairs of cranial nerves. In this system, sensory fibres transmit impulses to the brain and motor nerve fibres to the effector organs. There are eight cervical nerves, twelve thoracic, five lumbar, five sacral and one coccygeal nerve. All these supply the skin, bones, muscles and joints of a particular area. The spinal nerves leave the cord from both sides (fig 136). Each nerve is formed by the union of a motor and sensory nerve, and has contributions from the sympathetic and parasympathetic systems. It is important to understand the anatomy of nerve roots. This will help us to study the effects of asanas and pathological states like a prolapsed disc.

The spinal nerves

These leave the cord through the side, via the foramina. Each nerve is formed of both motor and sensory fibres and is divided into a dorsal and ventral root. The ventral carries the motor fibres and the dorsal the sensory. Hence the dorsal root is regarded as being afferent, i.e., taking messages to the brain. The dorsal root has a swelling — the dorsal root ganglion. After this ganglion, the dorsal and ventral roots unite to form the spinal nerve. In the opening through which it finally comes out of the vertebral column, this nerve is in close relation to the intervertebral disc; it will therefore be pressurised if the disc herniates. Every spinal nerve, through the ventral root part of the anatomy, is connected to the sympathetic nerves also. The single nerve leaving the cord divides further into an anterior and posterior ramus (fig 137). The sympathetic communication is to the anterior part. The anterior ramus supplies the front and sides of the body, and the posterior, the sides and back of the body — skin, bones, joints and muscles. From the anterior part there are five large nerve plexuses on each side of the vertebral column: the cervical, the brachial, the lumbar, the sacral and the coccygeal plexus. These supply skin, joints, muscles and bones of a particular area. The thoracic region is an exception to this arrangement. Here, the nerves do not form plexuses but remain as pairs of nerves, 12 in number, which supply the intercostal muscles and overlying skin, and the muscles of the abdominal wall.

Fig 136 The spinal cord and the spinal nerves.

Hence, each part of the body is supplied by its own plexus of nerves: the cervical area by the cervical plexus (the diaphragm by the phrenic nerve, a branch from this plexus); the upper limbs and scapular areas by the brachial plexus; the lower limbs and abdominal muscles by the lumbar plexus (the lower limbs by the sciatic nerve, which has connections from both the lumbar and sacral plexus); and the pelvic organs and pelvic floor by the sacral and coccygeal plexus (figs 138, 139 provide examples of nerve supply to the limbs).

Fig 137 Diagram showing relationship between sympathetic and mixed spinal nerves.

Fig 138 The main nerves of the arm.

Fig 139 The main nerves of the leg.

The cervical posterior ramus supplies the muscles of the neck and skin in the posterior part of the body. The posterior ramus in the thoracic area furnishes the thoracic muscles on the posterior aspect (multifidus and longissimus — refer anatomy of back muscles in section on prolapsed disc), and the cutaneous branches. The lumbar dorsal ramus supplies the multifidus and the erector spinae. The sacral dorsal ramus serves the multifidus muscle and the skin over the gluteus maximus. The coccygeal dorsal ramus feeds the skin over the coccyx on the posterior aspect. Similarly, this arrangement persists through the anterior rami to the other side of the body.

Functions of the twelve cranial nerves Olfactory

serves sense of smell

Optic

sight

Oculomotor

moves eyeball, controls size of pupil

Trochlear

moves eyeball

Trigeminal

moves muscles of mastication, sensory nerves for face

Abducent

moves eyeball

Facial

function of taste, muscles of facial expression

Vestibulo-cochlear

sense of hearing, sense of balance

Glosso-pharyngeal

taste, salivary flow, muscles of swallowing

Vagus

muscles of larynx, pharynx, glands, etc.

Accessory

muscles of shoulder, head, pharynx, larynx

Hypoglossal

moves muscles of tongue

Figure 140 shows the optic nerve with its different parts. It can be clearly made out that part of the optic nerve from one side crosses to the opposite side of the brain so that the vision in one eye is controlled by the opposite cerebral hemisphere.

Fig 140 The optic nerve and the visual pathway.

The peripheral nervous system can suffer inflammation, degenerative changes (acquired or inherited), tumors, etc. The cranial nerves can suffer the same disorders.

The Special Senses The ear The ear is the organ of hearing (fig 141) and is innervated by the 8th cranial nerve. It is divided into three parts: (i) external ear; (ii) middle ear; and (iii) internal ear.

The external ear This part has the auricle and the external acoustic meatus. The auricle is the prominent portion of the ear. It is made of cartilage. The external meatus is about one inch long. The tympanic membrane is at the end of this. There are glands that secrete wax which serves to trap dust and other foreign bodies. The blood supply is from the external carotid artery. The veins drain into the jugular veins. The nerve supply is from the vagus and mandibular nerve, a branch of the trigeminal nerve.

Fig 141 Parts of the ear.

Fig 142 The internal ear

The middle ear The cavity of the middle ear is in communication with the throat by the eustachian tube. It has three auditory bones that serve to transmit sound — the malleus, incus and stapes. They transmit sound vibrations to the inner ear. Any pressure change in the eustachian tube at the pharyngeal end, or infection, is directly transmitted to the middle ear. Infection can also spread from the sinuses. The blood supply is from branches of the internal and external carotid arteries. The veins reach the jugular. The nerve supply is from the tympanic plexus — from the branch of the glossopharyngeal nerve and the cervical sympathetic nerves around the carotid artery.

The internal ear This is the part that contains the organs of hearing and balance. It has a bony labyrinth and, within it, a membranous labyrinth. Between these two is a fluid called perilymph. Inside the membranous area is a fluid called endolymph. The bony part consists of a vestibule, a cochlea, and three semicircular canals oriented in different directions (fig 142) for different planes of balance of the human body. The membranous part also has the same three divisions. Here, the vestibule contains the utricle and saccule. The fine hair cells of nervous tissue in contact with the endolymph form the true organ of hearing, the spiral shaped organ of Corti. In the walls of the utricle and saccule are fine hair cells which join to form the auditory part of the vestibulo cochlear (8th cranial) nerve. The cochlear part of the vestibulo cochlear nerve starts in the membranous cochlea. The different parts of the membranous cochlea are named in figure 143. The arteries of the cavity are six in number, mainly from the external carotid, and a few from the internal. The veins reach the jugular vein.

Mechanism of hearing The movement of the tympanic membrane causes the ossicles to vibrate. This is transmitted to the fluid in the inner ear and the cells in the organ of Corti pick it up. The cochlear part of the vestibulo cochlear nerve picks up the impulses and relays it to the brain. The semicircular canals are concerned with balance. The movement of the endolymph stimulates the hair cells in the utricle and saccule. The movement is perceived in the perilymph and endolymph. The three semicircular canals help in orientation of the head in space, balance and posture. The vestibular nerve from the utricle and saccule passes to the cerebellum which is important for posture and balance. The arteries are the branches of the basilar — an artery from the union of the vertebral arteries — and from the external carotid. The veins reach the jugular. The ear can suffer a variety of diseases like tumors, infections, allergic conditions, inflammation, congenital or genetic conditions like nerve deafness.

Fig 143 Section of membranous cochlea showing the organ of Corti.

The eye The eye is embedded in the fat of the orbital cavities. This is the organ of sight. The eyeball is made of three layers: (i) the outer layer or the sclera, with the cornea; (ii) the middle layer called the choroid; and (iii) the inner layer or retina.

The sclera This is the outer white coat. In the front it is continuous with the cornea. The sclera maintains the general shape of the eye and gives attachment to the extrinsic muscles of the eye. Its vessels are scanty and the nerves are from the ophthalmic nerve. The cornea is needed for clear transmission of light rays. If there is any damage to this surface, light is refracted in a chaotic manner and the person finds it difficult to see objects. The cornea is avascular and is composed of five layers. It has plenty of nerves which are branches of the ophthalmic nerves.

The choroid This is the middle vascular layer on the inner side of the sclera. The ciliary body is the continuation of this in front and is made of muscles. The ciliary muscle controls the shape of the lens. The iris, a continuation of the ciliary body, is a diaphragm. It controls the amount of light entering the eye. The ligament of the lens has its origin from the ciliary muscle. In the middle of the iris is the pupil which is the aperture of the eye. The iris is innervated by both parts of the autonomous nervous system. The color of the iris varies with race (fig 144).

The lens deflects the incoming light rays to focus sharply on the retina behind the iris (fig 145). It is an avascular structure behind the iris and in front of the vitreous body. This is transparent and biconvex. It has a capsule in front and behind and a central nucleus. The centre parts of the front and rear surfaces are the poles and the margin forms the equator. The substance of the lens is soft and made up of lamellae. No fibres pass from pole to pole. The lens contributes about 15 dioptres of power to the eye.

Fig 144 Choroid, ciliary body and iris (front view).

Fig 145 Section of the eye and the focusing of light rays on the retina.

The space between the cornea and the lens is divided into an anterior and posterior chamber by the iris which has circular muscle fibres. The aqueous humor is a fluid that travels from the posterior part, reaches the front chamber, and is absorbed. If the drainage is blocked for any reason, acquired or congenital, the pressure on the retina builds up. If it exceeds a certain limit, the retina is permanently damaged, resulting in blindness. This condition of raised intraocular pressure is called glaucoma. This humor is responsible for maintaining the intraocular pressure and is a pathway for metabolic events in the avascular structures of the eye. It carries glucose, amino acids, a high concentration of vitamin C, and mediates exchange of respiratory gases. Behind the lens is a jelly-like substance called the vitreous body. This helps in the general shape of the eyeball. It is composed of 99% water and some salts. The sphincter pupillae is a non-striated muscle bound by tissue to the end of the dilator pupillae which lies behind the iris. The sympathetic nerves dilate the pupil and the parasympathetic constrict. The arteries of the iris are from branches of the ophthalmic artery, itself a branch of the internal carotid.

The retina The retina is the innermost layer of nervous tissue consisting of 10 layers. It has light sensitive pigments in the nervous layer of rods and cones. The termination of the optic nerve in the retina is the

area of the optic disc (fig 146). The cells of the retina join to form the optic nerve and two nerves from either eye cross each other. In this crossing, the fibres from the nasal half of one retina cross over to the other side (the retina can be divided into a nasal half and a temporal half). The latter refers to the proximity to the temporal bone (‘temple’, in layman’s terms). The optic nerves ultimately reach the occipital lobe in the cerebrum; some reach the cerebellum, by which they coordinate vision with the sense of balance. The retina has rods and cones. The rods are used for night vision. The cones are sensitive to bright light and color. The visual pigment known as rhodopsin is present only in the rods. This requires an adequate supply of vitamin A. This pigment is bleached by light and hence the rods are kept inactive in bright light. The blood supply is from the central artery of the retina, a branch of the ophthalmic artery. There are no arterial anastomoses in the retina and blockage of a part of an artery results in loss of vision in that part only. The central retinal vein drains venous blood.

Fig 146 The retina as seen through the pupil.

Fig 147 The extrinsic muscles of the eye.

Fig 148 The lacrimal apparatus showing the direction of flow of tears.

The human eye has binocular vision and images are fused into a single one. The eye has several muscles that move the eyeball in different directions. There are four straight (rectus) and two oblique muscles. The medial rectus muscle rotates the eyeball inwards, while the lateral rectus rotates it outwards. The superior rectus rotates it upwards and the inferior rectus does so downwards. The superior oblique muscle rotates the eyeball so that the cornea turns in a downward and outward direction; and it is turned upward and outward through the action of the inferior oblique (fig 147). The other parts of the eye include the conjunctiva and the lacrimal apparatus (fig 148). The conjunctiva is a fine membrane serving to protect the front of the sclera and the cornea. The ophthalmic artery supplies it. The lacrimal glands are responsible for tear secretion and are situated in the upper outer corner of the eye. The secretion of tears ultimately reaches the nose by the nasolacrimal duct. Tears serve to wash off dust and other particles and thus protect the eye. If the production of tears stops, the surface of the eye will be rapidly eroded by dryness and bacterial inflammation.

Fig 149 The olfactory structures.

All parts of the eye can suffer tumors, infections, inflammation, inherited or acquired degeneration, and allergic conditions. The olfactory nerve This nerve serves the function of smell (fig 149). It has an olfactory bulb which continues into the corresponding nerve. The nerves pass to the temporal lobe in the cerebral cortex through the roof of the nasal cavity. Animals have a better sense of smell than man. Any kind of nasal disease affects the sense of smell. In smokers, this sense is badly affected. The nose can suffer tumors, infections, allergic conditions (to which it is easily susceptible), and bleeding.

The taste buds These are distributed on the tongue, palate, pharynx and epiglottis. The nerve supply is by the seventh, ninth and tenth cranial nerves. The taste areas are located in the cortex. The areas of taste are: sour at the sides of the tongue, bitter at the back, and sweet and salty at the tip.

The Reproductive Systems The male reproductive system This includes the following organs: (i) the testes which are the reproductive glands of the male (similar to the ovaries of the female) with the epididymides, the spermatic cords and the vas deferens; (ii) the seminal vesicles; (iii) the ejaculatory ducts; (iv) the prostate gland; and (v) the penis (fig 150). The testes The testes are enclosed in a sac called the scrotum. Each testis has its own epididymis and spermatic cord. The epididymis is a collection of a number of seminiferous tubules that leave the testis and unite to form a single structure called the vas deferens (deferent duct). This passes along the spermatic cord to join with the seminal vesicle on its side. The testes have three layers of tissue around themthe tunica of three types (fig 151). They are suspended in the sac by the spermatic cord. The cord is composed of lymphatic vessels, arteries, nerves and smooth muscle. It passes through a hole in the abdominal muscles called the inguinal canal. The blood supply is from the testicular artery, and the venous drainage by the testicular vein. The nerve supply is from the 10th and 11th thoracic nerves.

Fig. 150 The male reproductive organs and associated structures.

The main hormone secreted by the testes, testosterone, comes from the cells in between the tubules of the testes known as the interstitial cells of Leydig. This has androgenic actions on the body. It promotes protein build up and helps fuse long bones. Its principal actions are formation of sperms, maturity and differentiation of the cells of the body. The male secondary sexual characteristics like the pattern of hair growth, muscle mass, deepening of voice, are all due to the androgenic actions of this hormone. This is converted into an active form, called dihydrotestosterone, in some tissues, especially the skin and the prostate. Elevated levels of this hormone are believed to cause benign enlargement of the prostate gland in men. The testes also produce Estrogens.

Fig. 151 Longitudinal section of a testis, its coverings, and a deferent duct.

The seminal vesicles These lie behind the bladder. There are two vesicles and each sends a duct to join the vas deferens on its respective side to form the ejaculatory duct. The vesicles secrete a viscous fluid to nourish the sperms. The ejaculatory ducts These ducts pass through the prostate gland and reach the urethra, emptying the seminal fluid here. The prostate gland This is in the pelvic cavity in front of the rectum. It secretes a fluid which nourishes the sperms (fig 152). It surrounds a part of the urethra and, if this part is enlarged, obstruction of urinary outflow can occur.

The penis This consists of erectile tissue and involuntary muscle. It is richly supplied with blood and is innervated by the autonomic nerves and somatic nerves. The stimulation of the parasympathetic causes engorgement of the penis. Semen is the fluid ejaculated from the urethras during coitus. The semen passes from the epididymis, deferent duct, ejaculatory duct and the urethra into the vagina of the female. It basically consists of sperms which normally number 100 million per ml. (fig 153), a viscid fluid to nourish the same from the seminal vesicles, and mucus secreted from the lining of the urethra. The normal quantity of seminal fluid is around 2-3 ml. Successful spermatogenesis occurs at about a temperature of 3° centigrade lower than normal body temperature.

Fig. 152 Section of prostate gland and associated reproductive structures on one side.

Fig. 153 A spermatozoon (from the side).

Fertilization is difficult if the count is very low (below 30 million) but advances in fertility medicine have helped such situations where one healthy sperm is isolated and fused with the healthy egg. The male reproductive system can suffer a variety of disease conditions. These include congenital anomalies, infections, testicular tumors, prostatic inflammation and enlargement (both benign and malignant). The female reproductive system This can be divided into external and internal organs. The external organs (fig 154) include the labia majora and minora, which are folds of skin with numerous sebaceous glands. The clitoris corresponds to the penis in the male. It contains erectile tissue but has no reproductive role. The hymen is a mucous membrane covering the opening of the vagina. The internal organs include the vagina, the uterus, the fallopian tubes and the ovaries.

Fig. 154 The external genitalia in the female.

Fig. 155 Female reproductive organs in the pelvis and associated structures (lateral view).

The vagina The vagina with two fornices is a muscular canal for the passage of sperms to the uterus. The pH of the vagina is acidic; this inhibits the growth of many microbes. During menopause it turns alkaline, favoring the spread of pathogenic bacteria. The blood supply is from the internal iliac artery, venous drainage of the same name, and nerves from the sympathetic and parasympathetic. The uterus This is a pear-shaped organ in the pelvic cavity between the bladder and the rectum. The uterus is bent forward, almost at right angles to the vagina and resting on the urinary bladder. It also leans forward (fig 155). The uterus has a body, the internal os and external os. The latter opens into the vagina. At the sides of the uterus are two fallopian tubes which serve to transport the ova into the cavity of the uterus for fertilization (fig 156). The lining of the uterus is thick with three layers of tissue: the perimetrium, the myometrium, and the endometrium (fig 157). The organ is supported in place by a number of strong ligaments: two broad

ligaments, two round ligaments, two utero-sacral ligaments — the last of which reach the front of the sacrum and either side of the rectum. There are also two cervical ligaments from the sides of the vagina and the cervix. The blood supply is by the uterine arteries and the nerves are both the sympathetic and parasympathetic. The fallopian tubes These are around five inches long and have fimbriae at their ends. They serve to waft the ovum and mucus into the uterus.

Fig. 156 Female reproductive organs in the pelvis and the main ligaments supporting the uterus.

The ovaries The ovaries lie in the pelvic cavity on the lateral walls and are attached to the upper part of the uterus and to the broad ligament by their ligament. There are two parts, the cortex and the medulla. Maturation of follicles depends on follicle stimulating hormone (FSH) from the pituitary. The lining cells produce Estrogen. After

Fig. 157 Section of the uterus.

ovulation the lining cells change into a corpus luteum under the influence of luteinising Hormone (LH). This produces the hormone progesterone. If the ovum is fertilized, it secretes a hormone called human chorionic gonadotrophin (HCG) which stimulates the corpus to continue secreting progesterone (fig 158). The menstrual cycle occurs once in around 28 days and the sequence of events is the same as described above. If the ovum is not fertilized, the high levels of progesterone inhibit the levels of LH and this causes degeneration of the corpus luteum, and the level of progesterone falls. The lining of the uterus starts degenerating and bleeding occurs. The bleeding occurs for two to five days; this is highly variable. The regeneration of the lining starts all over again in two phases. The first phase is until ovulation occurs and the next is until bleeding starts. From the day of ovulation, there is a period of 14 days after which the corpus luteum begins to deteriorate.

Fig. 158 Section of an ovary showing the stages of development of one ovarian follicle.

Hypothalamus & Pituitary FSH

LH

Ovarian follicle

Corpus luteum

Estrogen

Progesterone

The mammary glands These are accessory glands of the reproductive systems, which exist in a very rudimentary form in the male. In the female the breasts start maturing after puberty, under the influence of estrogen and progesterone. The breast consists of glandular tissue, supportive tissue and fat cells (fig 159). Lobules unite to form lobes. All the ducts from the lobules join to form several excretory ducts, which converge towards the center of the breast, forming reservoirs for milk. From here, ducts lead to the nipple. The surface of the nipple is kept healthy by sebaceous glands. The blood supply is from the axillary, intercostal and mammary arteries; veins of the same name. Nerve supply is from the 4th, 5th and 6th thoracic nerves which have sympathetic connections. There are sensory nerve endings in the skin around the nipple which, when stimulated, cause release of milk preceded by the flow of the hormone oxytoxin.

Fig. 159 The breast.

Menopause can begin between 40 to 50 years of age. The entire system becomes less responsive to hormonal stimulation. There are various side effects in this period which include flushing sensations, palpitations, sudden sweats, shrinkage of breasts, disturbance of sleep pattern, atrophy of sex organs, and change in the mineral content of the bones leading to osteoporosis. The flushes, which are particularly troublesome, are due to pulsatile release of LH. Depletion of the rich estrogen receptors in the vagina causes itching, irritation, dryness, and painful intercourse. The bladder is also estrogen responsive, and hence, frequent urinary infections are common. The uterus atrophies. The supporting structures also become less healthy and there is a tendency towards prolapse of the uterus. The female genital organs are prone to a variety of lesions. Different parts can suffer various ailments like inflammation and infection which are the most common, cysts of the ovaries and fallopian tubes, uterine tumors (benign and malignant), tumors and infections of the breast, etc.

Yoga as a Means of Preserving the Body The short description of the anatomy and physiology of the human body would have helped interested readers understand how our body works. It is truly a marvelous piece of machinery—“What a piece of work is a man!” said Shakespeare—but, like all machines, it is prone to break down under unfavorable conditions. As I have mentioned briefly under the various systems, each of them is liable to be affected by disease states. With increasing advances in medicine, it is possible to treat and control most diseases. But the side effects of every kind of medication are to be reckoned with. Hence, we focus on preventive health care right from the start. To continue the analogy of a machineproper maintenance of our body maintains it without problems for most of our life. The practice of asanas and pranayama is unquestionably an ideal method to preserve the health and longevity of our body. Yoga is unique in that it recuperates the system. Minimal cellular exhaustion occurs. Due to internal massage, the cells liberate their toxins more efficiently. Blood flow is increased with augmented oxygen delivery to the tissues. Free radical release is much less than that in other systems as the strain is minimized. The mind is kept in contact with the cells and action is based on the input from the periphery. The adjustment is deliberate, and the practitioner’s awareness is so refined that awareness of subtle functioning or malfunctioning of any part of the body is more perceivable. During practice there is enough time to impose corrective action, as the poses are slow and steady. Ultimately, yoga is designed to regulate and integrate cellular functioning from moment to moment. Medicine has now recognized the power of mind over matter. Yoga has been using this property all along. Asanas work on gross and micro structures. For example, the effects on cartilage, synovial lining and bone can be directly observed as asanas are practiced. If there is synovial inflammation due to trauma, certain asanas heal the area by their ability to remove the pent up products of cellular inflammation and promote better blood flow by intra-articular massage. As the actions in asanas are both contractions and extensions, both the softness and rigidity of connective tissue are preserved. The facial skin is a typical example of maintenance of integrity. Due to regular practice of Head stand, the skin always has a healthy sheen. This is due to preservation of water content, blood flow, and the requisite intracellular distension, maintaining cellular tension with blood and fluid. Yet another example is that of adipose tissue. Due to the unusual nature of yogic movements, the body is shaped and sculpted so that fat formation is optimum, and a person never gains or loses more than what is needed in the relevant areas. Yoga is a conscious, yet an automatic,

massage process in a geometric manner without actually kneading the tissue with the hands. The internal massage occurs by a natural process due to the practice of the asana. It is anatomical and hence no damage occurs.

Joints and muscles Yoga acts on the joints unlike any other system. The joints are given an internal massage. The internal tissues are aligned and massaged in an anatomical manner. This is labeled joint servicing. Smooth, soft, supple movements with alignment, and a steady state of stretch or contraction, are available only in yoga. The range of movements surpasses that in any other science. This ensures that the joint is used through the full range of movement. While practising yoga, the mind is trained to be aware of multiple joints for alignment and other minute details. Hence it is a holistic method. Yoga has always stated that to maintain life in any part— for the cells to grow and survive —stretching is important. Science has determined that cells that are subjected to stretching are able to grow better, adapt and survive (Science; 1997; 276: 1426-28). Yogis are said to have lived long; this was because of the kind of exercise they did on a long-term basis. Science states that cells that bulge do not survive long. Yoga does not allow bulging of cells. One can perceive that yogis have had a better understanding of the human body. In the type of stretch or contraction given in yoga, the muscles are precisely positioned in certain planes, and alignment is given before the stretch commences. The regional blood flow changes, but mostly without any reflex change in any other parameter. Secondly, as there is no repetitive movement, the muscles do not get exhausted. The muscles trained thus remain healthy throughout life.

The skin The effect of different asanas on the skin (which is a major organ) deserves special mention. It is necessary to enhance and maintain skin blood flow. In yoga, adequate time and a varied geometry are available to push the blood, with varying stresses and strains, even to the remotest of areas. In standing poses, the skin is trained to become highly sensitive as a tactile instrument. Touch, pressure, vibration, temperature and pain sensations of the body are sharpened. As the adjustment in standing poses are from segment to segment, every pore of the skin serves as an afferent instrument sending relays to the brain for efferent action of correction in posture. The sensory nerve endings on the skin are razor sharp due to the stretch given to them by the asanas. These, in turn, maintain the neurovascular functions of the skin. In fact, if the skin is injured in a particular area, practice of asanas is difficult as there is loss of feedback to the mind from that area. Skin and nerves are connected, and standing poses tone up both parts simultaneously. The blood supply to these nerve endings is enhanced by the asanas, preventing senile changes in the skin. The healthy functioning of the organs of perception also depends on the nerve endings in the skin. Standing poses tone up peripheral circulation. Hence the skin blood flow is stimulated. All parts of the skin are made to open up and healthy sweating occurs. The heat developed is not excessive. The asanas, by virtue of their different geometric shapes, stretch or contract every part of the skin. In inversions, the entire surface of the skin on the body becomes cool, which the practitioner can

actually feel. This is due to the soothing action on the nervous system and the net effect on the glandular functions. The temperature-regulating center of the hypothalamus is soothed, and the body temperature reduces. But the inner body feels warm after the poses. In forward bends, the skin on the front of the body is contracted, with reduction in blood flow and increase in temperature. The blood flow on the posterior aspect is enhanced due to the stretch- the skin becoming warm initially and cool later on. The muscles feel warm immediately due to the enhanced blood flow. The facial skin is particularly cooled, even during asana practice. This is due to the effect of pratyahara occurring in forward bends. The disconnection of the mind from the senses, and the mind becoming introspective, reduces the temperature of the skin. In twisting poses, the skin is stretched, contracted and massaged. The effect is one of softening, better blood flow. No stagnation of secretions occurs and resultant bacterial infections such as boils, warts and cysts are prevented to a reasonable extent. The oil content of the skin is preserved and, in fact, enhanced in needed areas. Sweating patterns are of a mild nature. In balancing poses, the skin is made intensely warm. Sweating patterns are moderate to intense. The skin on the abdominal area is always warm due to the repeated action of contraction, though it is also extended at times. If balancing poses are completed with Urdhva Dhanurasana, the skin on the abdominal surface is stretched and cooling occurs later on. Back bends stretch the front of the body. The skin is ‘cooled’ as are the abdominal organs. The skin on the posterior aspect is contracted, and sweats due to the heat generated as the muscles contract intensely. The facial skin becomes warm due to the load on the skull and organs of perception in back bends. The skin on the posterior aspect of the legs also becomes warm due to the contraction, the front of the legs remaining cooler. In pranayama, as the entire mind and body are kept silent, the whole surface of the body is cooled. In a nutshell, the skin is adducted, abducted, rotated and circumducted in yoga. It is used as a tool of intelligence, and the yogic practitioner justifies the saying, “Health is a glow from inside.”

The cardio-vascular system Let us now briefly see how the practice of yoga can help prevent disorders in the other systems of the body. A healthy cardio-vascular system prevents many other disorders as all systems are interrelated. The massaging action of asanas is valuable for the interstitial space (the space between cells filled with tissue), which improves micro-nutrition by healthy lymphatic flow. Arteries and veins are massaged and kept elastic, and atherosclerotic blockages prevented. It is essential that the heart and the arteries remain soft and supple with the capacity to adapt. This means that even under conditions of stress, the system does not malfunction. This is real inner strength. Yoga is the only means to provide this, as cellular mechanisms are regulated in the yogic system.

The respiratory system In today’s polluted world, it seems impossible to ensure a healthy respiratory system. Yet, yoga has

provided the science of pranayama to preserve it. Pranayama strengthens the inner vital energy at microcellular levels. This vital body cannot be measured by any medical means and is the very source of energy within us. It is essential to retain the elasticity of the lungs, to increase the uptake of oxygen, ventilate every cell in the lungs, and massage the lungs to promote longevity. Yoga ideally suits this need. Asanas promote and maintain the elasticity of the ribs and intercostal muscles. The diaphragm is also attended to by all asanas working in different directions. Standing poses stimulate the lung. Inverted poses, by virtue of the weight of the abdominal organs on the diaphragm, toughen the lungs. Forward bends train one to breathe in a limited cavity. Twisting poses work on the same principle, but in an asymmetrical manner. Back bends are ideal for invigoration, promote excellent immunity, and strengthen blood circulation in the entire lower respiratory tract. Practice of pranayama maintains cellular integrity of the respiratory passages. The cartilages of the trachea and smaller bronchi are toned up by asanas and pranayama. They remain soft and elastic. The vocal cords are kept resilient by pranayama, and inverted asanas — particularly Sarvangasana and Halasana — improve blood supply to the same area.

The digestive and excretory systems Yoga is unique in that asanas can massage the gastro-intestinal tract. They promote expulsion of excessive wind; maintain peristaltic functions, blood supply, and freshness of the tissues; and regulate transit time. The esophagus and stomach are benefited by all asanas, particularly back bends. Motility and blood supply are increased and all physiological functions toned up. The pancreas is benefited by rotational movements as it lies perpendicular to the axis of the spine. Inverted twisting poses like Parivrittaikapada Sirsasana are very helpful. Back bends are valuable to improve blood supply to the organ and refresh the cells. Asanas massage the liver, maintain perfusion, enhance elimination of toxins, etc. A healthy flow of blood brings in its wake immune cells to circulate properly in the substance of the liver. If the contractions of the gall bladder are not healthy, stagnation can predispose the organ to stones. Asanas massage the gall bladder and prevent any stagnation of secretions. They keep the lining of the gall bladder healthy and ensure proper peristaltic contractions in response to hormones. The kidney is a vital organ performing many functions. Many die from renal diseases due to different causes. Diabetic renal disease is particularly disabling. The tissues are damaged by deposits of excessive cellular matrix. The increased sugar alters the structure of peptides. The arteries become thick. Asanas can delay and prevent these changes, provided the diabetic starts yoga at an early stage. Back bends are valuable for this purpose. Ascending infection from the bladder can be prevented by regular practice of inverted asanas. Baddha Konasana is invaluable for preventing inflammation of the urethra in both males and females. Recurrent urethritis can be prevented by these asanas. The health of the entire urinary tract can be well maintained by regular practice of yoga.

The hematological and immune systems

Asanas massage the tissues and preserve a fluid state of circulation. In yoga, the auto massage on the tissues can help break some plaques that form on the vessel wall. However this may not happen in all cases. Anti-clotting factors are mobilized as in any exercise. The massaging action of asanas brings the muscles closer to the bone, pushing blood into the marrow which is responsible for healthy cell production. The increase in immunity levels of the body in yogic practice is due to the reduction of stress levels of the mind and body, and pooling of blood in the different parts of the body. As the asana is released slowly, the effects of blood pooling remain in that area for some time. With such stimuli applied daily; the body remains healthy and is more resistant to infection. The massage to the spleen, thymus, and the circulatory system, including the lymphatics and the nodes, results in an alert and energized immune system. No stagnation of bacterial debris is allowed and disposal of waste material is efficient. Massage of the tissues and making the immune cells remain in the area is an important mechanism in yoga. I would re-emphasize reduction of stress as another principal method. Our system functions in an orderly manner only when there is a certain amount of quietude. Chances of immune dysfunction are reduced. The massage to the skin increases blood flow to those areas which enhance and maintain healthy output of anti-bacterial secretions to promote immunity. The blood circulation to the soles, which lack sebaceous glands, is promoted by asanas and this develops local immunity. Muco-ciliary clearance systems are stimulated, aiding the immune system to function better. Excellent circulation of body fluids spreads the cells of the immune system to different areas.

Glands Yoga is the only system where it is possible to voluntarily reduce glandular secretions. The main aim of asanas is to preserve glandular function and maintain energy. The stimulation does not exhaust glandular secretions. Hence, the practitioner emerges fresh even after two hours of yoga practice— actually fresher than pre-practice levels. Power and vitality are side effects of good glandular function. All asanas are useful, particularly inverted poses. Back bends stimulate, forward bends recuperate, and passive poses energize the system. Asanas have stimulating and suppressive effects on the male sexual organs. Forward bends, Baddha Konasana, and Upavishta and Samakonasana inhibit physical stimulation. Back bends increase the strength of the sexual drive and the contracting capacity of the muscles of ejection. Pranayama, by its disassociation of the mind from the senses, controls mental drive over the physical organs. The same principle applies to the female.

The nervous system The concept of the nervous system in yogic thought is most interesting. Anatomically, according to western medicine, there are several major and sub plexuses along the entire length of the body in front of the vertebral column. Some of the major ones are the coccygeal plexus, sacral plexus, lumbar plexus, hypogastric plexus, coeliac plexus, epigastric or solar plexus, gastric plexus, cardiac plexus, cervical plexus, and pharyngeal plexus. All are in communication with each other, and with the

sympathetic and parasympathetic nervous systems. The yogic texts describe centers or chakras which are points of energy. These are not physical matter but energy centers. Mastery of the functioning of each of these leads to specific capabilities. According to yogic texts, positive and negative energy, represented by the pingala and the ida nerves, pervade the body. The pingala is on the right side of the body and the ida on the left. The pingala stimulates the functions of the mind and body, while the ida suppresses them. This aptly corresponds to the sympathetic and parasympathetic nervous systems. The chakras correspond to the autonomic nervous system. The human body can be described as being made up of three parts: the sthula sarira or gross body; the karana sarira or causal body; and the suksma sarira or subtle body (which cannot be physically felt, only sensed, as in inhalations and exhalations of breath). The yogic chakras and nerve plexuses that correspond with each other are described below. The Muladhara chakra is situated in the pelvis, above the anus. It is said that the Muladhara chakra is concerned with nourishment, absorption and elimination of waste matter. It is the seat of the annamaya kosa or the body of nourishment. Mastery of this chakra also leads to control of sexual energy. According to medicine, the inferior hypogastric plexus (a branch of the hypogastric plexus) innervates the organs of the pelvic cavity and muscles of the rectum, with fibers to the penis and sensory fibers to the vagina. It is joined by branches from the 2nd, 3rd and 4th sacral nerves. Part of the large intestine and the rectum are supplied by nerves from the superior hypogastric plexus which has communication with the sympathetic and parasympathetic nerve, the vagus. The coeliac plexus is one of the largest plexuses of the autonomic system. It is situated at the level of the first lumbar vertebra. The coeliac ganglia also supplies part of the large intestine. The small intestine is supplied by the coeliac ganglia. Though the coeliac plexus does not lie in the pelvic cavity, the chakra probably controls its functions. The small intestine is concerned with absorption of food. The Svadhisthana chakra, situated above the organs of generation, corresponds to and controls part of the hypogastric plexus which supplies nerve fibres to the colon, prostate, uterus and vagina. This chakra is the element of water and smell. The colon is important for absorption of water and balance of the moisture content of the faecal matter, and hence, the tissues of the body. Mastery of this leads to a disease-free state. The Manipuraka chakra in the navel area is the element of fire. It controls and corresponds to the gastric plexus (a part of the coeliac plexus) which supplies the stomach and, in conjunction with the vagus, controls acid flow in the organ. The Svadhisthana and Manipuraka chakras form the pranamaya kosa—the physiological body. The Surya chakra corresponds to the solar or epigastric plexus which lies behind the stomach and innervates all the abdominal organs. From the epigastric plexus are derived all the plexuses: the renal, supra-renal, spermatic, coeliac, superior mesentric and aortic plexuses. The coeliac plexus of

nerves forms the coeliac ganglia and gives rise to the phrenic, gastric, hepatic and splenic plexuses. The superior mesentric plexus is part of the coeliac plexus. The Manas chakra lies between the Surya and the Anahata chakras. It is the seat of emotion, imagination and creativity. It is difficult to find a physical plexus to correspond to this chakra. The Anahata chakra lies in the region of the physical heart. It corresponds to the cardiac plexus. The Manas and Anahata form the psychological sheath— the manomaya kosa. The Visuddhi chakra lies in the region of the throat, above the chest in the base of the neck, and corresponds to the cervical and pharyngeal plexus. It represents the intellectual sheath — the vijnanamaya kosa. Mastery of this leads to distinct, fluent and clear speech. The Ajna chakra represents the abode of joy—anandamaya kosa (karana sarira or causal body) and lies in the center of the forehead. This corresponds to the region of the thalamus. When activated, the person is always joyful. It actually means that equanimity is achieved and the person is naturally blissful. The Lalata chakra is at the top of the forehead, corresponding to the cortical centers. It helps proper awareness and perfect action in all situations. The Soma chakra cools the body, akin to that part of the hypothalamus which has receptors for regulation of body temperature. The Sahasrara chakra is the center of the supreme spirit. Mastery of this means liberation. This is the harmonious functioning of all parts of the mind and brain, thus qualifying for the state of samadhi as described by Patanjali. The texts describe the nadis. These are channels for passage of vital energy. The nadis penetrate the entire body from the soles to the crown of the head. All the nadis originate from the Kandasthana and the heart. Twelve digits above the anus, and just below the navel, is a bulb known as the Kanda. This releases 72,000 nerves, and from each of them another 72,000 branch off. According to the Kathopanishad, 101 nadis radiate from the heart. From each of these another 100 set out; and from each of them again, 72,000 emerge. The Siva Samhita lists 350,000 nadis. I have given below a list of 10 of them with their respective organs. The three most important are the ida, pingala and susumna. The susumna lies in the center of the spinal column and this position corresponds to the central nervous system of western anatomy. The ida starts in the left nostril, goes to the crown of the head and then downwards to the base of the spine. The pingala nadi does likewise, starting from the right nostril. Solar energy is said to flow through it, hence it is also called the Surya nadi. The ida is the Chandra nadi, or the conduit for lunar energy. The ida and pingala nerves criss-cross at the chakras, and are, therefore, interconnected with the susumna. This is also true of western thought where it is said that the sympathetic and parasympathetic nerves are in connection with the nerve plexuses and with the spinal cord.

The other important nadis are: Gandhari, originating in the left eye; Hastijihva, in the right eye; Pusa, in the right ear; Yasasvini, in the left ear; Alambusa, in the mouth; Kuhu, in the genital region; Sankhini, in the anus. Nadis may also correspond to arteries, veins, and the channels and ducts of all the systems. They function as inlets and outlets of various energies. According to the Siva Samhita, when food is digested, nadis take the best part of the nourishment to the subtle body (suksma sarira), the middle part to the gross body (sthula sarira), and the inferior part is discharged as faeces, urine and sweat. Nadikas are smaller nadis and nadi chakras are ganglia. Modern science has also described nerves for every part of the body, but there is a difference. According to yogic thought, these nerves cannot function by themselves but have vital airs that enable them to function. These airs are: prana, udana, samana, vyana, apana, naga, kurma, krkara, devadatta and dhananjaya. Prana vitalises the heart. Udana activates the throat (melodious voice). Samana energises the navel region (digestion). Vyana is crucial in the entire body. Apana is vigorous in the region of the anus (excretion and digestion). Naga is essential to the act of belching. Kurma opens the eyelid. Krkara causes sneezing. Devadatta is responsible for yawning. Dhananjaya pervades the entire frame, even after death. Though western anatomy assigns specific nerves for each part of the body, sometimes it cannot explain functional disorders. A situation often arises in clinical medicine when investigations do not reveal any abnormality even when the patient demonstrates clear symptoms. The physician is left with no method to treat such a situation. A simple example is that of a burning sensation in the stomach not related to stress or food intake. If investigations do not reveal any pathology, the problem is labelled as a ‘functional disorder’. No remedy in western medicine helps. In such a situation, yoga says that the gastric fire (Manipuraka chakra) suffers over stimulation. Back bends are prescribed and the patient gets the necessary relief. Many other examples can be mentioned. Practice of yoga regulates the health of the nervous system similar to the other systems of the body. The chakras are activated and the practitioner remains alert to a ripe old age. All categories of asanas are useful. Standing poses stimulate the chakras. Back bends stimulate the chakras vigorously. Forward bends soothe chronic headaches while back bends strengthen the nerves to prevent headaches. All nerve roots are toned up by asanas. The spinal cord is massaged, and the blood supply to the cord is maintained. Inversions maintain healthy electrical transmission in the brain and prevent senility. Asanas and pranayama refresh the mind as recuperation occurs. The sympathetic and parasympathetic nervous systems are the gates through which yoga works. These are connected to the chakras and regularizing the activity of all these is beneficial to the system.

The special senses The practice of yoga deeply affects the special senses. Eyes are the areas where tension and fatigue show up earliest. The use of bandages over the eyes in asana and pranayama practice cuts off visual sensation, in addition to acting like a pressure bandage. This is useful in certain cases of glaucoma, hypertension and nervous fatigue. The moisture content of the eye is preserved. The entire structure of the orbit remains soft, elastic and healthy. The auditory sensations are also toned up by yogic asanas. The blood supply to the inner ear is optimized, preventing senile nerve deafness. The integrity of the delicate balancing mechanism is preserved. Inverted asanas are valuable for this, especially Sarvangasana and half Halasana. Back bends maintain the vibratory capacity of the bony ossicles. This also helps prevent age related hearing loss. Practice of pranayama with the bandage removes stress from the eye and ear. Introspection occurs. The loss of contact with the external world provides rest for the eye and ear. After prolonged practice of asanas and pranayama, the taste buds become razor sharp. This is something that can only be subjectively experienced. Sitali pranayama is the only type where the tongue is opened and folded like a leaf. This invigorates the taste buds on the tongue. It also affects the flow of saliva. In fact, after practice of pranayama, the secretions in the mouth are virtually zero. This is a sign of temporary hibernation. To summarize, yoga provides relaxation to the body by working through the special senses. The very perception of the relaxation is through the special senses. In this context, it is very useful to understand the value of the yogic technique called Shanmukhi Mudra which provides complete neuromuscular relaxation to the special senses. The nerves of the eye, ear and face are relaxed in this practice, and when the nerves are relaxed, their function is razor sharp. Since the control is voluntary in comparison to sleep, the effects are, depending on the need, sometimes superior to rest. Patanjali has said: “Perfection of the body consists of beauty of form, grace, strength, compactness, and the hardness and brilliance of a diamond.” (Yoga Sutras, Vibhuti Pada, III.47). Practice of yoga is one method by which all the systems of our body can be maintained at peak form to achieve such perfection.

SECTION III EXERCISE, ASANAS, PRANAYAMA AND PROPS Exercise is the only tool for a healthy life; yoga surpasses all other systems of exercise. Why should one exercise? What is the difference between yoga and other systems of exercise? Why is yoga an optimal system of exercise? This section provides detailed medical answers to these questions and focuses on the why and how of asanas and pranayama as well as the marvel of props in the execution of yoga, for both the unwell and the healthy.

The Importance of Exercise We have discussed the functional anatomy and physiology of the human body and understood its working. This chapter deals with the need to exercise and the advantage of the yogic system compared to others. At the end of the chapter I have summarised the salient differences between yoga and other systems. Yoga is unlike any system of exercise. The methods of exercising are different: the mind is given immense importance, there are precise explanations and instructions on various aspects like timing and sequence of asanas. It is a detailed science and in order to understand it, it is important to know why we should exercise at all. Many do not exercise and yet live to a ripe age. But the quality of life of such persons will not be as good as one would like it to be. Living is not important — living with excellent health throughout is more meaningful. Exercise, yogic exercise, is the only tool that can maintain health in a cellular sense. It is noninvasive and without side effects. However, practice of asanas and pranayama needs what modern thought calls motivation and Patanjali calls ‘tapas’. Recall Patanjali’s heyam dukham anagatam. This is preventive medicine according to ancient logic. To undertake preventive steps one must understand the effects of aging on the human body. Aging is the diminished ability of the cells of the body to react and adjust to the internal and external environment. Let us review what happens to the body in the various systems as we grow older.

Cells The aging cell has a poorer capacity to remove the normal amount of free radicals formed in the body. Retention of free radicals, as discussed earlier (see chapter on cell), is toxic to the body. The dwindling capacity is multifactorial in origin — stress, poor nutrition, unhealthy living and lack of exercise. Anti-oxidants try to counter the existence of free radicals and slow the aging process. The three most important anti-oxidants are superoxide dismutase, catalase and glutathione peroxidase. Other enzymes capable of removing radicals include vitamin E and C, and beta carotene. Aging of the cells is associated with a decline in protein synthesis and cellular proliferation, thus affecting the turnover of anti-oxidants.

Cardiovascular system

The cardiac muscle atrophies with age. The coronary arteries become blocked with plaques, reducing coronary flow. This can lead to a heart attack resulting in death of the tissue — an infarct. The size of the capillaries in the skeletal muscles diminish, and muscle blood flow is reduced. The elasticity of the blood vessels weakens, adding to flow reduction. This increased tension in the peripheral vessels causes an increase in blood pressure and reflex strain on the heart. The heart has to pump harder to maintain a healthy circulation. As the cells do not derive a healthy supply of blood, retention of cellular toxins damages the tissues. Calcification of major and minor blood vessels occurs, much depending on the diet, age and sex, physical activity, level of atmospheric pollution (Occupation and Environmental Medicine, 1997, 54: 535-40) and genetic predisposition to the condition. Atherosclerosis, which means hardening of the arteries with resultant reduction in blood flow to the affected area, is a major killer in the world today. The arch of the aorta becomes calcified. The aorta can also be dilated due to senile changes. All blood vessels in the body undergo degeneration, particularly in the heart and brain. Intramuscular reduction in blood flow leads to difficult and painful walking, as the working muscles do not get adequate flow at times of demand. The intracellular enzymes of the heart muscle diminish in quantity and quality, affecting the quality of cardiac contraction. The aging nervous system affects the rate and rhythm of the heart which slows down; this is due to reduced sympathetic drive and domination of the parasympathetic nervous system.

Respiratory system The lining of the nose suffers reduction in blood supply. This leads to a dry and stuffy nose and crust formation. Ciliary function is poorer. The reflexes of the nasal lining to changes in external temperature are less effective. The sinus cavities suffer stagnation of secretions and poor clearance. Ciliary motility is affected. Drainage passages of the sinus into the nose become ineffective. The nasal part of the pharynx suffers reduced blood supply and the lining of the cavity is not as healthy as before. Stagnation of secretions leads to sinus and upper respiratory infections. The capacity of the trachea and the rest of the respiratory tree to expand and contract is reduced. This affects the proper flow pattern of inhaled and exhaled air. The bronchi and bronchioles receive less blood and hence function less healthily. The cilia lining the respiratory tree do not clear toxins, debris, bacteria and other pathogenic material efficiently. Infections can result. Reduction in the elasticity of lung tissue increases the work of breathing. Pulmonary capillaries reduce in size and number, affecting ventilation and perfusion of gases. The alveoli dilate, retaining inhaled air. The elasticity of intercostal muscles and ribs is reduced, making breathing difficult. The diaphragm becomes rigid and inelastic retarding the proper up and down movement of the lungs and circulation of the energy drawn in. Clearance of toxins in the respiratory system is thus affected. The vital capacity of the lungs diminishes and the person is not as energetic as before. The cells not being able to secure a healthy supply of oxygen, cellular metabolic reactions are affected. The mitochondria need an adequate supply of oxygen. Lack of this affects generation of energy in the body.

Digestive system Atrophy of the salivary glands leads to decreased salivation, dryness of the mouth and impaired digestion. Oral ulcers and inflammation of the tongue (glossitis), with loss of taste, occur due to atrophy of the taste buds. Loss of teeth due to weakening of tissues and retraction of the gingiva (gums) is common. Swallowing is difficult because of weak pharyngeal muscles. Blood flow to all the organs reduces, to the detriment of their efficient functioning. Reduction in esophageal motility makes swallowing difficult and prolongs its peristaltic activity. The muscle layer of the stomach is not as efficient as before, and the action of churning food is weaker. The cells of the stomach atrophy, resulting in diminished acid outflow and poor appetite. Improper nutrition affects body weight. Secretion of the ‘intrinsic factor’ (important for absorption of vitamin B12) is affected. Iron absorption is also poor due to reduced acid output. This causes anaemia. As acid secretion is reduced, invasion of the stomach by pathogenic organisms leads to gastritis, bloating, belching and excessive wind formation with discomfort (dyspepsia). Reflex responses of other glandular secretions to unloading of gastric contents into the duodenum is sluggish, with resultant indigestion and fat malabsorption. The cells of the liver function less effectively. Carbohydrate intolerance, with diminished ability to handle a glucose load, is due to an aging pancreas with loss of islet cells. The gall bladder atrophies impairing the excretion of bile, leading to fat emulsification with formation of gall stones. The amount of subcutaneous fat in the body reduces. Sensitivity of the body cells to insulin also decreases with age. The smooth muscles in the walls of the intestines become inelastic, causing retention of gases. The peristaltic capacity of the ileum and colon becomes weak. This hinders proper absorption of food and water, with reduction in assimilation. Elimination of waste matter is sluggish. Build up of colonic toxins increases the chances of colon cancer. The cells in the wall of the colon get dehydrated. This reduces the water content of waste matter, causing the passage of dry stools and consequent constipation. Piles and fissures result. The anal sphincter becomes weak. The cellular function of the alimentary tract is affected due to poor blood supply. The flow of digestive juices decreases. The villous cells of the intestine suffer poor blood flow and lymphatic circulation, and hence absorption of nutrients is poor. Hardening of the arteries affects the blood flow to the gastro-intestinal tract. An emergency condition, ischaemic necrosis of the wall of the intestine, can be caused. A diet poor in fibre and lack of exercise lead to diverticulosis, a condition where the walls of the intestine form sac-like dilatations. These harbour bacteria due to stasis of intestinal contents.

Body metabolism With aging, body metabolism is never the same as before. Due to poor physical activity, the metabolic rate slows down. This is aggravated by poor absorption of food. The hampering of circulation, respiration, nervous and glandular functions further affects metabolic activity. Efficient metabolic activity is an expression of inner energy.

Renal system The kidney is one of the organs where changes due to aging show up clearly. Blood flow into the filtration areas being reduced, cellular functioning is affected. The quality and quantity of urine outflow is altered. The organs start shrinking. Hardening of the renal arteries causes rise in blood pressure in the body, due to certain reflex chemical changes. The bladder wall suffers from poor tone and bladder capacity reduces. Stasis of urine is common, due to poor muscle function leading to urinary infections. The prostate enlarges, pressing on the urethra. Symptoms of outflow obstruction may be severe enough to require surgery. Aging of the female urinary tract is dealt with in the discussion of menopause, as the condition is linked to hormonal changes.

Nervous system As the blood flow to the various organs is affected, the brain starts shrinking. The cells in the brain cannot regenerate as before and their efficiency is reduced. The delivery of nutrients and oxygen is reduced due to a weaker heart, which further affects the functioning of the brain. This sort of change occurs in all the divisions of the nervous system, resulting in their poor functioning. Increase in the build-up of toxic waste material in the interior of the neurons causes various diseases. The speed with which the nervous system reacts to physical and mental situations is affected. The intellectual functions of the mind — sequential thinking, analysis, observational capacities — are all affected. Sleep is reduced. Hardening of the blood vessels causes cerebral ischaemia and sudden rupture and bleeding. Ischaemia leads to dementia and loss of memory, motor and sensory functions. The most common situation is when a person finishes a meal and suddenly insists that they have not eaten at all. There are many specific clinical diseases due to all these changes. As the brain is one of the centres of energy, poor functioning causes lack of vitality throughout the body. The cerebellar cells atrophy, affecting balance and coordination. Gait is affected. The regulatory centres in the cerebral cortex and medulla controlling cardiovascular, respiratory and endocrine functions become less effective. The lower centres in the spinal cord do not exercise adequate bladder and bowel control, resulting in uninhibited voiding and defecation. The centres in the spinal cord function less effectively. More time is taken to transmit and act on messages to and from the brain. An infarction of the cord leads to paraplegia.

The special senses Blood supply to the eye reduces and the retina becomes paler. The macula — an area in the retina, of the highest visual resolution — suffers reduced blood supply. Night vision is hampered. The choroid becomes less vascular. The nerves supplying the iris become sluggish. The dilating and constricting capacity of the pupil is less effective. The cornea becomes less transparent due to a diminished flow of fluid in the tissues of the eye. The passage which allows fluid to flow from the posterior to the anterior chamber becomes blocked, resulting in raised intra-ocular tension — glaucoma. Lipids are deposited on the edge of the cornea, causing a characteristic lining of the entire corneal curve, known

as arcus senilis. Associated elevation of serum cholesterol is often present. The conjunctiva and sclera become dry as the tear gland is not as effective as before. Poor or total stoppage of tear secretions irritate the eye, with resultant inflammation and infection. The lens becomes opaque, causing cataract formation. The blood flow to the ear is reduced, resulting in nerve deafness. The balancing mechanism is also affected. This leads to diminished ability to adjust to postural imbalances and even normal activity. The nasal lining (with the fine innervation of the nerve) atrophies, reducing healthy olfactory capacity. Taste buds atrophy.

Reproductive system The aging female reproductive system, with the problem of menopause, has been dealt with in previous chapters. In the male, atrophy of the testicular cells occur and spermatozoa do not maintain their vigour. Cancer of the testes and prostate is more common in this age group. Sexual dysfunction is common.

Endocrine system The glands function less effectively, and the response to any kind of stress — physical or mental — is weaker. The glands are very important for optimum metabolic activity, one of the most important being the activity of the thyroid gland. Hypofunctioning is common in old age. Glandular function is important for many functions in the body — absorption, utilisation, enzyme actions and storage of absorbed material. The blood supply to the pituitary reduces, and the connection with the hypothalamus is less effective. The pancreas does not perform as before. The adrenal glands are probably the most affected. The level of chemicals in the gland is lower, and the ability of the gland to react to acute situations is weaker. Energy levels are thus reduced. Ability to handle carbohydrate, protein and fat is diminished. The capacity to bear physiological stress is limited. As the endocrine system is also responsible for bone and muscle health, poor functioning of the glands affects them. Bone density is deficient, as is muscle mass. This is also related to poor dietary intake and lack of exercise. Decline in glandular functioning leads to overall decline in energy, enhanced susceptibility to infections, diminished physical drive and wasting of the body. Recovery from fatigue takes longer due to decreased capacity of the cells to respond to stimuli.

Muscles, bones and joints Muscle mass reduces as one grows older, due to lack of proper intake and absorption. Yet another major reason is disuse atrophy because of lack of exercise. Muscles are very sensitive to usage or the lack of it and suffer deconditioning very rapidly, especially if the person has been in the habit of exercising regularly. The difference is more perceptible here. The enzymes available in the muscle cells also reduce, affecting contractile capacity.

The connective tissues of the body become rigid and desiccated. This affects the resilience of the musculoskeletal system, causing greater mechanical load on the joints. Loss of flexibility in the joints results in arthritis. Reduced water content in the discs makes for loss of resilience, decreases the height of the spinal column, causes rigidity of the associated structures (ligaments and muscles) and increased incidence of fractures. Associated age-related disc degeneration is common. The mineral content of the bone reduces due to poor nutrition and absorption, lack of exercise and, in women, menopause. The deposition of calcium in women’s bones is an estrogen-dependent mechanism, and lack of this results in osteoporosis. Body movements are slower. Injuries take time to heal due to reduced vascularity of the tissues. Increased stiffness in joints can cause periarthritis of the shoulder and osteoarthritis of the finger, spine, knee and shoulder joints. Fractures of the hip are common. General body usage is more tiring than before and recuperating takes time. Aches and pains are more common. The menopausal woman suffers more from musculo-skeletal disorders. The entire machine is at a low ebb.

What have we learnt? It is obvious from the above that there is no medicine that can prevent all these systems from failing in old age. Exercise and a healthy diet are the only answers. It has been shown by epidemiological observations that a lifestyle which is based on these two essentials greatly precludes the risk of certain kinds of cancer (MSSE, Dec 1992). In other areas also, it is easy to understand the role of exercise — for example, in preventing circulatory stagnation and joint problems, and in stimulating glandular secretions. Patanjali has said: "Tivrasamveganam Asannah" (tivra = vehement or intense; samveganam = those who are quick; asannah = drawn near, or near in time); meaning, "the goal is near for those who are supremely vigorous and intense in practice". (Iyengar, B K S, Light on the Yoga Sutras of Patanjali, Indus, New Delhi, 1993. "Samadhi Pada", I.21.) Medicine has found out that age is no bar to improving ones’s exercise capacity which, in turn, improves health. There are a variety of exercises. All the systems, except yoga, can be put into one basket. In general, the more severe the exercise, the more the level of free radicals produced. During exercise (except yoga), oxidative reactions increase and damage to tissue is bound to occur. Overexercising the body produces more radicals and underexercising fails to remove the toxins. The optimum amount of exercise enhances the defence systems of cells which remove free radicals. When a radical reacts with an unsaturated fatty acid of the cell structure, a new radical is formed. In the presence of oxygen this new radical initiates a process known as lipid peroxidation of cell membranes, resulting in cellular swelling and tissue inflammation. When lipid peroxides split, the hydrocarbons pentane and ethane are formed. The levels of gases increase with heavy exercise. Now, with yoga, the process of exercise is totally different. The process is light and energising, unlike endurance exercises; moreover, asanas help remove cellular toxins. Yoga, being a steady and slow system, does not result in free radicals being formed as fast as they are removed, as in other exercises. Asanas and pranayama induce cellular quieting, thus inducing a state of hibernation. Yet,

the body is exercised. Yoga is the only ‘hibernative exercise’. Hence, free radicals are removed by the massaging action of asanas and optimum formation of radicals is maintained throughout the practice session without irritation. According to yoga, the mind controls the production of free radicals, both at rest and during exercise. If there is excessive stress of the mind, the body suffers. If the mind is not used, the body still suffers stagnation of radicals. A healthy mind optimises free radical production and removal. In other systems, the mind is exhausted and strained. One of the key points in yoga is that the asanas are practised with proper alignment and centring. There is a precise method and only one optimum way in which the right effect is given to the internal organs. In other exercises, the organs are not directly affected. In yoga, the liver or spleen may be directly massaged, the brain directly rinsed with blood, not at the expense of any other parameter. Other exercises act as irritative systems, by increasing pulse rate and blood pressure. At this expense, circulation is improved. During exercise, blood is shunted away from the skin and certain other areas to nourish the vital organs and the muscles. It might be dangerous for the cardiac patient to jog, as the heart can be irritated; but in yoga, there is no irritation as the heart can be rested in the asanas, yet coronary flow benefitted without strain. The mechanisms of improvement in blood flow are discussed in the chapter on asanas. Another special benefit of the asana system is that the body is stimulated if underfunctioning, and quietened if overfunctioning. The heart has a blood flow rate of 250 ml per minute, the brain a flow rate of 750 ml per minute. The liver has a flow rate of about 500 ml per minute, and the kidney a flow rate of 1200 ml per minute. Atherosclerosis reduces these with age. Yoga prevents this change, maintaining blood flow by automassage and preventing deposits being formed in the blood vessels. Moreover, blood is channelised to the organs in a very controlled way. Energy levels are very high in a body in which circulation of body fluids is well maintained, blood flow to the vital organs well preserved, and the intake of oxygen equal to that of a man in his twenties (even at an advanced age). For a normal person, the capacity to maintain cerebral perfusion in different postures — from sitting to lying down — is known as orthostatic tolerance. Athletes, used to high intensity training, where the volume of blood increases several times and the nerves are set to a higher level of stimulation, were found lacking in this capacity. Such changes do not happen to the yogic practitioner. The blood and plasma volume do not increase in yoga as the very nature of exercising is different. Hence, an athlete would benefit by asana practice along with endurance training. As one ages, the process of atherosclerosis advances. This can be prevented completely by the science of yoga as the asanas directly stretch the arterial wall, preventing stagnation of blood flow. Yoga prevents changes in skeletal, renal, hepatic, neurological, cardiac and pulmonary systems by various mechanisms. The asanas act by rinsing organs with blood. This improves their cellular functions and maintains the elasticity of all the tissues. To a great extent pranayama prevents atmospheric damage to the cardiac system, as it washes

away accumulated toxins in the blood. Yoga has always said that breathing removes toxins from the body. Only now does science postulate that toxins in the atmosphere can affect the heart and blood vessels (Occupation and Environmental Medicine, 1997; 54: 535-40). In the yogic system, the mechanism is quiet and restful. Asanas provide a soothing effect on the outer and inner organs. The result is organ tranquillity. Other exercises irritate the organs due to the harsh nature of the stimulus provided. In yoga, preferential shunting of blood is possible. The circulation to the skin is not at all reduced as in endurance exercises. On the contrary, blood flow to the skin is enhanced due to the massaging effect of the asanas. The shunting of blood in other exercises is involuntary, whereas in yoga one can shunt blood to any area consciously, as the geometric shapes of the asanas vary. The lungs get exhausted in endurance training. The mitochondria are flogged to the maximum with respect to their cellular power and respiratory functions. The strong lung capacity of an athlete is achieved by hard and forceful usage which is not conducive to preserving health. One can maintain the health of the lungs by the practice of back bends which are tough in their own way. All other asanas are also useful. The abdominal organs are shaken to the maximum while running. Again, a forceful method is used as the pace of organ functioning is raised. The mechanical effect of the asanas — squeezing, rinsing, flushing, pressurising, etc — preserve cellular integrity very well. The delivery of nutrients is enhanced and, at the same time, there is no wastage of reserves. The asanas promote blood flow to the oral cavity (inverted poses) and maintain all the organs in the cavity. In other exercises, blood flow to the oral cavity and its respective organs are reduced, thus dehydrating the system. In other systems, the cellular reserves are exhausted by other exercises. Yoga loads the battery and keeps it charged ready for discharge. When one is tired, other forms of exercises cannot be performed. Yoga has certain restful postures that re-energise the body under such conditions. This is the greatest advantage of yoga — an exercise which is useful during fatigue. The nerves are not exhausted in yogic practice. Though exercise improves energy levels by boosting the nervine functions, it is possible to achieve the same effect without exhaustion. In the long run, soft and gentle methods are more conducive to health. The endocrine glands are the keys to healthy energy levels. The hormones are not over used in the practice of asanas. In endurance exercise, the glands get exhausted. Endurance training results in heavy excretion of cellular waste products and wastage of body protein which strains the kidneys. The excitability of a nerve is inversely proportional to its activity. In everyday life the usage of nerves is so erratic and exaggerated that, at the end of the day, we have very little energy left. Sleep provides rest to the cells of the body. Yoga is like sleep, where the sympathetic tone of the body falls, as asanas are maintained in a very silent and still manner without much effort. The mind is kept very quiet for several hours at a stretch and profound relaxation occurs in both body and mind. The nerves thus recover very fast. One feels soothed after a prolonged practice of asanas because of rest to the sympathetic system which brings the body temperature to a lower level. Temporary hibernation occurs and the basal metabolic rate falls.

Gravity acts on the human body and tires it by constantly exerting traction on the nerves, veins and arteries. Yoga has poses that reverse the effects of this ‘G’ force so that lightness is imparted to the body. An organ that feels light is healthy. Owing to inverted asanas, aging in the central nervous system is avoided. This is due to the energisation of certain important nerve centres in the cerebral cortex and the brain stem. Muscle biopsy studied from persons who have trained by other exercises shows change in cellular architecture (for example, in body builders). In yoga, cellular structure does not undergo any change as the nature of stimulus is different and hence there is no need for the body to adapt. The muscles are often ‘damaged’ in endurance training. The chemical reserves are often altered. Depletion of glycogen is possible. In yoga such changes do not happen. The effect on the bones is one of a pounding action in other exercises. In yoga there is no pile-driver action, but a steady strain where a single or a group of muscles may be contracting and stretching at the same time. This combined action on a single muscle is unique to yoga. Hence yoga can be classified neither as isometric nor as isotonic. This action feeds the bone with healthy blood for the marrow. Where all other systems build up the bone in a convex shape, yoga does not cause hypertrophy. The bones remain strong yet slender in appearance. Physiologically, there is no need for the bones and muscles to hypertrophy for efficient function. According to yoga, a muscle is healthy if its blood supply is maintained and it is mechanically sound. During menopause, the side effects of flushing, sudden sweats, palpitations, bone pain, fatigue, can all be debilitating. Asanas and pranayama help regulate the actions of the autonomic nervous system through which many side effects of menopause are mediated. It has been shown that exercise is of great value to the menopausal woman, reducing osteoporosis and other mechanical changes. As menopause is a period of stress, yoga is ideally suited. Special asanas relieve fatigue and these are done with props. The effect of exercise on the immune system is a field of intense research. There is definite evidence that exercise helps better functioning of the immune cells. In yoga, regional immunity can be improved because the blood can be flushed into any area. This increases the concentration of immune cells in those areas. For example, in patients suffering from recurrent sore throats, the practice of Sarvangasana greatly reduces the frequency of infections. Immunity is also improved by the destressing the body and mind. It is well known that under stress the functioning of the immune system is affected. We know the skeletal movements of extension, flexion, rotation and so on. Every organ has to be treated in this way. This is known as healthy exercise. There is a certain methodology to be followed in the practice of yoga. Patanjali has said: "Vitarkabadhane Pratipaksabhavanam" (vitarka = doubt; badhane = suffering or pain; pratipaksa = opposite, contrary; bhavanam = affecting, manifesting or feeling); meaning, "principles which run contrary to the yamas and niyamas are to be countered with the knowledge of discrimination". (Iyengar, op.cit., "Sadhana Pada", II.33.) This can be also interpreted as follows: if

there is pain on one side while doing yoga, analyse the side that has the pain, analyse the side that has no pain, then try to do the same good movement on the affected side. This requires great sensitivity. The movement in yoga has to coordinate the skin, muscles, joints and inner organs, all in a single movement of the asana to obtain correct effects. This is integrated yogic practice, which has to be done mathematically and geometrically. The asanas have to be practised with lightness and vigour and not in a heavy, lethargic manner. There is no age bar to the practice of yoga. In the Hatha Yoga Pradipika it is said, "any person who is not lethargic in the pursuit of different forms of yoga attains siddhi through practice, be he young, old or even very old, sickly or weak". (Swatmarama, Hatha Yoga Pradipika, I.64.) The props help in the execution of the poses. Other exercises may be contraindicated for a patient with a cardiac problem, or hypertension, or some other ailment. But yoga can always be practised, with asanas specified for the medical problem. I have summarised below the salient differences between yoga and other systems of exercise. This will give the value of yoga in a nutshell.

Yoga compared to other systems of exercise Heart 1. Cardiac nerves are rested. 2. Heart rate is not irritated in yogic practice. 3. When the nerves are stimulated, it is a highly conscious process. 4. Asanas can massage the heart. 5. Blood pressure is regulated and, even if it rises, it is far lower than levels during aerobic exercises. 6. There are no adaptive changes in the blood vessels and heart as in athletes. 7. There is preferential shunting of blood flow in asana practice. 8. Quality of flow is soft, wafting or forceful as desired. 9. This force is unique, not pounding and pulsating action. 10.Many cardiac ailments can be treated by yoga: it is safer, direct in its approach and less irritative than other systems.

Circulation

1. There is no change in orthostatic tolerance in yoga. 2. Circulation is without strain. 3. Circulation is along anatomical lines, by massage. 4. Flow can be changed in any direction by changing asana shape. 5. It is without exhaustion. 6. The velocity of flow can be changed voluntarily. 7. There are no adaptive changes in blood vessels. 8. Arteries and veins remain soft and elastic. 9. One area can be massaged, while in another area the flow can be maintained or changed.

Lungs 1. There is no breathlessness. 2. Asanas have a massaging action. 3. Elasticity of cells is maintained. 4. Every part of the lung is attended to by the asanas. 5. Yoga stabilises sympathetic and parasympathetic nerves, ensuring optimum performance of airways. 6. There is greater intake of oxygen causing more storage and excellent blood flow; hence, ventilation and perfusion are maintained always. 7. Cells of the lungs are not ‘flogged’. 8. Elasticity of ribs, intercostal muscles and diaphragm is attended to. 9. Back bending asanas are special, giving ‘aerobic’-like effects. 10.Lungs become strong, less affected by climate, altitude and infections.

Gastro-intestinal tract 1. Massaging is predominant on abdominal organs. 2. Depending on the asana, effects on each organ vary at any single moment.

3. Rinsing, flushing, soaking, squeezing, drying of the cells are the various mechanisms. 4. Digestive secretions can be increased or decreased. 5. While working on abdominal organs, asanas simultaneously work on the endocrine glands. 6. Effect on organs easily observable by ultrasound or scanning.

Renal System 1. There are no fluid and electrolyte disturbances, unlike in sporting events. 2. There is no load on excretory organs. 3. There is regulation of kidney functions due to direct organ massage and alteration in renal flow. 4. Muscular functions of bladder are well maintained.

Endocrine System 1. There is no depletion of hormones as in endurance exercises. 2. There is no disturbance in baseline values and postexercise values. 3. Yet the system is energised. 4. There is invigoration of neural connections of the endocrine system. 5. Inverted asanas have a special effect on pituitary, thyroid and parathyroid.

Nervous system 1. Yoga is a non-stressful, optimum method of exercise. 2. There is reduction of sympathetic tone and overdrive. 3. As adrenal glands and sympathetic nervous system are linked, energisation, not depletion, of hormones occurs. 4. Yoga refreshes, while other systems exhaust. 5. Other systems of exercise initially stress the body, though the final feeling is one of wellbeing. 6. The consistency of the nerves is soft and supple, preserving healthy electrical transmission. 7. Yoga achieves voluntary control of the autonomous system. Other systems achieve only involuntary control.

Locomotor system 1. Pounding action is not used in yoga. 2. There is no wear and tear even with chronic usage. 3. Joints, ligaments and muscles remain soft and supple. 4. Range of movement is greater in yoga than in any other system. 5. Chemical fatigue of the muscles does not occur in yoga. 6. Adaptive changes like hypertrophy, excess glycogen storage, rise in muscle enzymes, etc, do not occur in yoga. 7. Bones remain sturdy in old age due to the calculated, aligned load in asanas, especially balancing asanas. In the next chapter, I have dealt with the different types of asanas and their effects on the human body. The techniques of performing asanas are not dealt with, as this is not the aim of my book, which is to understand the science of yoga, and learn to use it as a primary tool of therapy wherever possible, or integrate it with Western medicine for acute and chronic ailments.

Asanas The word asana means posture. A steady and pleasant posture produces a profound state of neuromuscular relaxation. Asanas are not mere gymnastic exercises; they are postures that are maintained for a certain period of time. To perform these, one just needs a clean and airy space, with a mat on the floor. The limbs of the body act as weights and counter-weights. One develops agility, balance, endurance and great vitality by practising yogic asanas. Asanas bring steadiness, health and lightness to the body and mind. Each asana is an organic movement, deeply affecting the inner organs. For example, the practice of certain asanas improves the effort tolerance of the heart and lungs. Regular practice of sirsasana, provided it is done in the proper manner, maintains cerebral perfusion even when one is 70 years of age, thus greatly reducing the possibility of an ischaemic stroke. Asanas prevent reduction of regional circulation as we grow older. Atherosclerosis, a process that hardens the blood vessels, never occurs in a yogic practitioner. So there is no rise in the systolic blood pressure which commonly occurs in old age. Asanas have been evolved over centuries to tone up every muscle, nerve and gland in the body. They reduce fatigue and soothe the nerves. By performing these asanas, the practitioner first gains health. Health is not a commodity to be purchased by drugs. Drugs only remove diseases. The science of yoga, however, helps to maintain the health of the body at peak form. Good physical and physiological health leads to mental peace and tranquillity. The names of the asanas are significant and illustrate the principles of evolution. Some are named after vegetation like the tree (Vrksasana); others after insects like the locust (Salabasana); a few after animals like the tortoise (Kurmasana) and the dog (Svanasana), birds like the peacock (Mayurasana) and reptiles like the snake (Bhujangasana). While performing asanas, the practitioner’s body assumes many forms resembling these principles of evolution. First, one has to understand how asanas are to be performed. After the mastery of asanas, the practitioner passes on to the science of breath: pranayama. Premature practice of pranayama could be detrimental to the body. Anatomical perfection of the postures provides proper strength and alignment for the lungs and the nerves to practise pranayama. For example, if Ardha Matsyendrasana is done on the right side, it is noticeable that the right lung expands easily with breathing but it is difficult to ventilate the left lung. If deep breathing is done in this situation as is normally taught in yogic schools,

the left lung cannot be ventilated properly as the anatomical alignment is not correct. While performing the asanas, one has to adjust and align the left lung and the rib cage on that side in such a manner that the drawn in energy percolates to that part also. To achieve this, the relevant areas of the dorsal spine need to become flexible. Then, during actual pranayamic practice, or even when deep breathing is done when the asana is performed, the air inspired automatically reaches those areas. Patanjali has clearly mentioned that only after the mastery of asanas is pranayama to be practised. "Pranayama is the regulation of the incoming and outgoing flow of breath with retention. It is to be practised only after perfection in asana is attained." (Iyengar, op.cit., "Sadhana Pada", XI.49.) Nowadays, in many yogic schools, pranayama is taught along with asanas. This is not only medically harmful; it also goes against the tenets of Patanjali. Some asanas involve movement of the body in flexion, some in extension, some in lateral flexion, and some in lateral flexion and rotation. Every muscle and joint has to be properly positioned; otherwise, ill effects can ensue. Asanas, if improperly performed, can cause disorders; the proper practice of the same asanas can prevent the disorders. For example, wrong practice of Sirsasana (Head stand) can give rise to glaucoma and the same pose can prevent high intraocular tension. Similarly, wrong performance of Sarvangasana can cause cervical spondylosis, whereas the same pose is used to attain relief from this condition. Hiatus hernia, a common radiological finding after middle age, can be caused by wrong practice of Halasana. The same pose, if rightly done, can give relief to the patient. Virasana can damage the cruciate ligaments of the knee (situated deep inside the knee), if wrongly done. Right practice removes the strain on those ligaments. In asana practice, visual input provides for perfect adjustment combined with sensory feedback from the peripheral nerve endings on the surface of the skin. The ‘needle of consciousness’ is used to penetrate every part of the body to remove ill health. There are endless poses, every one of which, done rightly, benefits the body. But a balance is important. A body that is very good at flexion may not be good at extension or vice versa. To learn to extend the muscles and organs in every direction needs constant practice. An important point is with regard to pose and counter pose, which is the common method of yoga practice in most schools of yoga. The necessity of countering the asana movements is not queried. Because the texts say so, they are followed blindly, without a medical rationale. Medically, if the body is stretched laterally, as in Trikonasana, it is necessary to repeat the movement on the opposite side immediately, for even usage of the body. But if the body is bent to the front, it should not be bent back at once. This is harmful to the muscles as they have been intensively used in one direction for a period of time. That is why the majority of practitioners with back ailments do not get rid of their problem or suffer aggravation of pain by the time they come to medical professionals. If one feels the strain of a pose, it will disappear with practice. If the back aches after a back bend, Bharadwajasana on a chair will provide relief till the practitioner is strong enough not to suffer pain from a back bending pose. Patanjali has said, stira sukham asanam. If one does not achieve this, what is the use? In the process of perfecting an asana, there will be pain. We need to be intelligent enough to differentiate between healthy and unhealthy pain. Healthy pain disappears with practice, while the unhealthy does not.

When the body is bent forward, the senses are soothed and the brain is decompressed. This effect would be lost if one bends backwards at once. Moreover, all other effects of the forward bend on the rest of the body are also lost. The very idea of holding a pose for a period of time is to derive the benefits of it. If the pose is reversed at once, one would gain nothing physiologically!! If one were to finish the forward bend with a back bend, I would say, ‘my dear friend, now that the body has bent backward, bend forward again to reverse this effect’. Then where would it end? There is what is called the neutral gear in a car which principle, if applied in yoga, gives the solution. Certain poses are neither backward nor forward bends, e.g., the dog pose. If these are done one can, theoretically, reverse poses, even though one would still lose the physiological effects of the previous pose. To summarise, yoga has to be done in an integrated manner, understanding the medical logic in everything one learns.

Classification of asanas Asanas have been evolved to act on various parts of the body. Every possible direction that the human body can anatomically stretch or contract to is made use of in yoga. Sometimes, asanas are described as contortions. The word contortion means to twist or bend out of normal shape. It is necessary to use the body in such a way for certain specific reasons which we will discuss in the following pages. Actually, every exercise is some form of ‘contortion’. Yoga is a more ‘scientific contortion’ than any other. Every organ, muscle, tendon, nerve, gland, bone has to be precisely placed, the like of which does not exist in any other science. The physical adjustment, coordinated and motivated by the psyche, creates physiological changes in the body. There are a variety of asanas, and each has a different type of effect on the body. Some asanas share similar effects with regard to particular parts of the body. Asanas can be classified as follows: (i) standing poses; (ii) inverted poses; (iii) forward bends; (iv) seated asanas; (v) twisting poses; (vi) balancing asanas; and (vii) back bending asanas.

Standing poses Standing poses include Tadasana, Uttihita and Parivrtta Trikonasana, Uttihita and Parivrtta Parsvakonasana, Virabhadrasana I, II and III, Ardha Chandrasana, Uttihita Hasta Padangusthasana, Parsvottanasana, Prasarita Padottanasana, Padangusthasana, Uttanasana, Urdhva Prasarita Ekapadasana, Ardha Baddha Padmottanasana, and Adho Mukha Svanasana (see illustrations, pages 307, 308). We need to stand but poor, sloppy, misaligned standing postures lead to disorders of the spine, hips, knees, and of the internal organs. Added to this, we may have stiff lumbar and cervical muscles, tight hamstring muscles or, on the contrary, overflexible muscles, which make us suffer postural pain. To correct all this and avoid future problems, yogis have prescribed standing poses to maintain the health of the locomotor system. There are a variety of positions. Each has a different range of movement and affects several parts of the body simultaneously. When we stand erect, a part of the mind should constantly be aware of the posture and make necessary corrections for optimum weight distribution on

the legs and spine. The effect of standing poses on the various systems of the body are discussed below.

Locomotor system Standing poses are designed to give strength, endurance and grace to the body and legs. The spinal muscles are strengthened. All the inter-vertebral joints are kept healthy due to the rotational and lateral flexion, and flexion movements of the poses. Pain in the legs due to certain vascular or neurological causes does not occur. The peripheral motor and sensory nerves are kept energised and function healthily due to the stretch given. Thus, inflammation of the nerves does not occur as happens in certain kinds of peripheral neuropathy. All the joints of the body are kept supple, so arthritis and other degenerative disorders cannot occur. Suppleness, strength and alignment of the spine are maintained due to a variety of geometric movements. Hence spinal problems of a mechanical nature, like scoliosis, slipped disc, spondylolisthesis (where the spine slips forward towards the abdominal cavity), and chronic low back pain are averted. These are the most common and important clinical problems that are alleviated by standing poses. For example, the intervertebral disc ruptures only if the ligaments, discs and muscles lose their visco-elasticity. The nutrition to the disc is maintained by standing poses and the blood flow in the spinal arteries does not diminish. The hip joints are made supple due to the stretching of the hamstring muscles; any flexion movement occurs at the hip joints rather than at the spine, thereby reducing strain at the various spinal facet joints. Arthritis of the hip joints of any etiology does not affect a practitioner of standing poses. In certain conditions where the hip joint is damaged due to injury to the blood vessels supplying the joint, asana practice is very helpful to maintain joint mobility (e.g., Perthe’s disease, where the blood vessels to the ball of the hip joint are affected). Arthritis of the knees and ankle joints, calcaneal spur (a bony projection on the heels very commonly seen today, creating pain when walking and standing), distortions of the joint anatomy due to tears and injuries will all be greatly relieved by standing poses. Inflammation of the ankle joints and tissues of the feet are prevented by these asanas. The asanas nullify the effects of flat feet as strength is provided to the muscles and ligaments of the entire foot; the patient is relieved of the pain. Injuries to the cartilages of the knee, as happens in sporting events, are healed by standing poses. Even if the ligaments or cartilages in the knee are badly torn, surgery can be avoided and the structures strengthened (though not in all cases).

Heart and circulation The cardiovascular system is toned up by standing asanas though, unlike in aerobic exercises, there is little change in the pulse rate and blood pressure. All parts of the cardiac wall are toned up. The heart is massaged and stimulated. Lateral bends like Trikonasana attend to the outer part, rotational

movements attend to the inner part and inverted standing poses release the strain on the base of the heart. Inverted standing poses like Uttanasana, Adho Mukha Svanasana and Prasarita Padottanasana improve blood supply to the heart, lungs and brain. A practitioner can withstand high altitudes and various strains imposed on the heart as well as an athlete can. Negligible lactic acid is formed in the body during yoga. Energy flows to the body because of stabilisation of the cardiac nerves. Cardiac effort tolerance improves both in healthy persons and patients. The concept of using a treadmill test to diagnose ischaemia of the heart is illogical. How can a person who has not exercised ever do the stress test? In such a person, the body is naturally degenerating and the heart cannot tolerate the stress. The real clinical problem is when a person who has exercised regularly fails the test. Like sleep, yoga rejuvenates the system. Every yogic asana can be compared to sleep. During sleep the body is unconsciously brought to a still position. The blood flows to various areas to give the substrate to the cells to store energy for the system. During rest, only 12% to 20% of the capillaries are open. During exercise, particularly yoga, all the vessels are opened and an increase in the diastolic blood flow and oxygen content occurs. Through this, nutrients flow into the cells. Thrombosis of the veins in the calf muscles does not occur in a person who does these exercises. Stretching the arteries of the legs in the standing poses prevents claudication (painful limping), caused by insufficient blood supply. One can actually see the artery expanding as the asana is done, allowing more blood to enter the muscle (see Yoga and Medical Science : FAQ).

Respiratory system The dorsal spine which supports the lungs is well aligned in standing poses. Elasticity is given to the anterior and posterior inter-costal muscles and every alveolus opens out, so that oxygenation is better and the vital capacity of the lungs does not reduce as one ages. The directions of movement are so varied that all parts of the lungs are toned up. The cells of the lungs are kept soft and supple. The energy levels of the body are kept up. Better blood circulation is attained in the thoracic organs. The return of blood to the lungs is better as the thoracic organs are more elastic. Standing poses are the primary asanas after which forward bends and back bends train the lungs in a more intensive manner. Mastery of standing poses is also essential before pranayama can be introduced. Practice of pranayama is helped by the supporting structures of the lungs being elasticised. Moreover, perfect anatomical alignment is achieved in the lungs, preventing strain when pranayama is practised.

The abdominal organs The abdominal organs are massaged and the lymphatic circulation is toned up in standing poses due to the internal massage. Hence, the cells function better for a longer period of time. Absorption of food

is better, and intestinal peristalsis, gastric mobility, pancreatic secretions are all toned up. The process of digestion and excretion are stimulated. Regional blood supply does not reduce as one grows older. Atrophy of the organs can thus be prevented. The asanas lift up the abdominal organs and prevent their prolapse. This eliminates excessive wind in the intestinal tract. According to yoga, ill health of the abdominal organs is responsible for various other malfunctions. There should be a certain sense of lightness in the organs which is an indicator of health. Standing poses impart this quality. The nerve plexuses are stimulated and toned up. The corresponding chakras are energised. Hence resistance to infections is built up. Standing poses maintain the inner vital health of the organs.

Endocrine system The poses stimulate the glandular system. The glands are made to function with a quality of litheness. As the poses work on the periphery of the body and ensure optimum functioning, glandular secretions are healthily utilised without wastage. Metabolic rate of the body is speeded up as in back bends, though to a lesser degree. Receptivity of the cells to the stimulating action of the hormones of the body is maintained.

Reproductive system Poor posture, with the spine pushed forward while standing, displaces the prostate and, in due course, will cause it to press on the urethra. These poses teach the right method of standing. The bladder is toned up. The spermatic cord and the seminal vesicles are massaged. In women, standing poses pull up and tone the supports of the uterus. Prolapse of the pelvic organs and stress incontinence are prevented. The blood flow to the uterus is normalised, so that dysmenorrhoea is controlled. The lining of the vaginal wall is massaged, preventing any age-related atrophy. Better blood supply increases resistance of the vagina to infections. The asanas give proper alignment to the tubes and prevent pelvic infection. Ardha Chandrasana is very useful for painful periods and prolapse of the pelvic organs. The ovaries are specifically attended to by this asana. The urethra is strengthened by concave standing poses. During pregnancy, standing asanas help maintain the necessary strength and suppleness in the muscles of the spinal column so that back aches do not occur. The pelvic floor is stretched and kept elastic. Standing poses create a healthy state of circulation in the abdominal organs during pregnancy, preventing pressure effects of the enlarging uterus. The poses create extra space for the baby in the uterus. The uterine and placental circulation is toned up. Venous stasis that occurs in some women is prevented. The strain of bearing a child does not affect the musculo-skeletal system. Concave standing poses are very helpful. The woman must modify the standing poses as the sac enlarges with each month. The asanas could change the position of the baby if there are problems of malposition.

Nervous system If a person has to retain litheness of movement, grace and poise in old age, it is essential to practise

standing poses. They sharpen the neuro-sensory skills of the body. Tactile localisation and discrimination, pressure, touch, vibratory, pain and temperature sensations of the body have to be used while practising such asanas. All asanas are valuable. Balancing standing poses like Ardha Chandrasana and Virabhadrasana III are most helpful to give confidence, strength and agility to the practitioner. As the poses are being performed, the person must be aware of the different parts of the body that are pressed on the floor, ensure that the pressure is correct, adjust for maximum refinement, evoke corrective action by activating a muscle group or loosening a ligament or tendon. The areas for coordination and adjustment of balance and posture in the cerebral cortex and the cerebellum are thus stimulated, and such functions remain well toned up. It must be remembered that visual input aids balance and posture. Blood flow in these areas of the brain also increases, as does the metabolic activity. The peripheral nerves which are, according to yoga, the gnana nadis, are used properly. The efferent nerves or the karma nadis are also attended to. The connections of the peripheral nervous system to the brain through the spinal cord are well toned up. The spinal nerve root as it exits from the foramina in the vertebral column is massaged and kept healthy; hence compression of this root, as in a slipped disc, never happens. The motor organs of the body are stimulated, while the sensory organs, which are made quiet and observant, are refined and made alert; so neuro-muscular skills are retained. Proper timing is essential for best results. Most standing poses can be held for a minute or two. Repetitions are useful. Some of them, like Uttanasana, Svanasana, and Prasarita Padottanasana, can be held for a period of even five minutes. Individual guidelines are important. Patients with medical disorders can be safely guided through the poses with special modifications.

Inverted poses Inverted asanas, peculiar to the yogic system, include Sirsasana, Sarvangasana (and their variations), Halasana, and Viparita Karani (see illustrations, pages 306, 307). In no other system of exercises are inverted poses available. The yogis realised the deleterious effects of gravity and, at the same time, they understood the inherent effects of these poses on the body. For seven decades (or so) the human being stands erect. It is essential to reverse this situation to prevent stagnation of circulation and sagging of organs, enhance oxygenation in the lower parts and maintain the health of the body. Let us consider the effects of inverted asanas, system by system.

Cardiovascular system As the body is maintained in the inverted posture, venous return is enhanced. Blood flows to the heart without strain in all three inversions. Cardiac output improves. Cardiac toning occurs by these asanas; yet, without a rise in pulse rate or blood pressure. Medically, the poses can safely be performed by healthy persons for a period of 15 minutes each, but only after being taught by a competent professional.

Pressure of the abdominal contents against the diaphragm exercises the muscles of the diaphragm and the heart. The chambers of the heart are massaged. The myocardium remains healthy. Setu Bandha Sarvangasana, a variation of Sarvangasana, is excellent for improving contractility of the heart. Diastolic flow to the legs is increased in these exercises (see Yoga and Medical Science : FAQ). I have detailed, in the table (above), the cardiac parameters in a few asanas. The table provides echo cardiographic measurements of the heart in different postures. It is seen that in setubandha sarvangasana the pumping capacity of the heart is stimulated to the maximum. This happens without an increase in pulse rate or blood pressure. When such exercises are performed every day, the effects remain in the system just as regular exercise regulates cardiovascular fitness.

Scan 1Echo of the heart in supine posture (left) and in Head stand (right).

Head stand is very safe for the echocardiographic studies do not show any deleterious change in cardiac parameters in any of the inverted poses (scan 1). Cardiac parameters for the supine posture are as follows: IVS = 0.89 and 1.5; LPW = 0.98 and 1.77; LVD = 5.07 and 2.55; EDV = 122.12ml; ESV = 23.44ml; SV = 98.68ml; and EF = 80.8%. Elasticity of the aorta and the major blood vessels is maintained. The cardiac muscle, working to improve the circulation towards the legs, is toned up and well exercised. The flow to the legs is maintained and stimulated, even though the body is in an inverted position. This has been confirmed by ultrasound measurements (see Yoga and Medical Science : FAQ). Cerebral perfusion gradually reduces with age, leading to conditions like senile dementia and strokes. Practice of sirsasana totally prevents this change. Circulation of body fluids to the neurons is very healthy. Sirsasana could be very useful as a prophylactic tool for ischaemic strokes. As the asanas are done on supports for patients, there is no restriction on those suffering medical disorders. In Head stand, arterial circulation to the brain is stimulated and the cerebral artery tries to dilate, but maintains blood flow without an increase in pressure or velocity. Hence, cerebral circulation is healthier with maintenance in fresh blood flow. Studies have shown that the intraocular venous pressure does not rise in head stand, if properly done. This makes the pose safe even for persons with glaucoma of a particular type (scans 2, 3, 4 & 5). Scans 2, 3 and 4 demonstrate the blood flow — in the erect posture and in head stand — in the carotid system and the cerebral arteries. The circulatory system of an ordinary person is like a stagnant pool, where the water flows every day but not with a certain quality of dynamism. Scan 5 illustrates that there is no deleterious effect on the eye for a normal person who practises Head stand. Of course, modifications are needed for patients whose intraocular pressure is raised. This is done with the elastocrepe bandage wrapped around the eyes. Before this, practice of forward bends are essential for a few months to condition the eye, followed by half Halasana and Shoulder stand on the chair. Head stand is done with the ropes for those whose intraocular pressure is elevated to prevent excess strain on the eye.

Asanas soak the entire system with fresh blood every day. They rinse, dry, squeeze and flush the various areas.

Scan 2Blood flow in the internal carotid artery (ICA) in the erect seated posture.

Scan 3Blood flow in the ICA in Head stand.

An example of soaking can be given in sirsasana where the facial tissues are bathed in blood. Like a sponge which will become brittle if not used properly, the brain also turns brittle and this can result in a stroke. If the sponge has to work well, both soaking and draining actions are essential. This way of conditioning the body keeps up the vitality of the cells and halts premature aging. The inner lining of the entire arterial and venous system is preserved by inverted asanas, especially in the brain. By head and shoulder stands, the lymphatic and venous systems of the legs are given rest from the constant strain of the ‘G’ force. The formation of varicose veins is prevented (not in all cases). Persons with varicose veins secure great relief by inversions. Though the veins remain dilated, the constant inversion relieves congestion and prevents further dilatation. The symptoms of the patient are nullified. Lightness is felt in the leg at once, lasting for several hours — which no medicine can provide. The use of the crepe bandage for such problems is only a crutch. It retards proper circulation though preventing dilatation of the veins. It does not provide relief. The patient is advised to elevate the legs on the bed by the use of several pillows, but this hardly provides relief as the inversion is not sufficient. Unless the body is totally inverted venous congestion is not relieved.

Respiratory system In the upper respiratory tract, the secretions of the nose and paranasal sinuses drain well and stagnation never occurs. Freshly oxygenated blood flows into the sinuses. The oral cavity derives better blood supply, maintaining the health of the mucous membranes. The pharyngeal area is perfused with fresh blood pooled in this place by these poses, so that infections are never recurrent. This is particularly valuable for children. These poses cure chronic sinusitis. Particularly good are Shoulder stand and half Halasana which open the sinus passages and allow free drainage into the nose. Later,

Head stand is needed. Regular practice prevents sinus disorders and allergic problems of the upper respiratory tract. In the lungs, as enhanced venous return occurs, more pulmonary veins and capillaries open up. This ensures better pulmonary circulation and cellular longevity. The rhythmic pressure of lung movement against the diaphragm exercises the entire respiratory tree and the cells of the lungs. This happens without a rise in oxygen consumption. This is the peculiar feature of yogic exercises. Vital capacity of the lungs improves by regular practice. The capacity to withstand altitudes is derived from inverted poses. When practised at high altitudes, the lungs are warmed up immediately.

Scan 4Blood flow in the middle cerebral artery (MCA) in Head stand.

Proper drainage of secretions takes place in the lungs, maintaining a clean airway. Due to deep breathing, the lungs open up and enhance the dynamics of body fluids. Immunity of the respiratory system is improved due to better circulation of T and B cells. The bronchi and vocal cords obtain better blood circulation due to internal heating. Sarvangasana and half Halasana are particularly valuable for the vocal cords, sinuses and nasal passages as they cleanse the area. The sensitivity of the sinus passage is maintained. The well-exercised dorsal spine massages the lungs from the posterior aspect. The asanas can be practised with or without the props (see chapter on yoga and its rehabilitation equipment), as the situation demands. They prevent aggravation of the medical condition and obtain anatomical precision. Most major clinical disorders, like asthma, bronchitis, and sinusitis, are alleviated by regular practice.

Abdominal organs The oral and pharyngeal cavities are benefited by better blood supply. The tongue, salivary glands and mucous membrane are all bathed in fresh blood. In inverted poses, healthy displacement of the abdominal organs leads to changes in mechanical stress and strain. This helps to eliminate excess wind from the colon and stomach. The abdominal organs are massaged, improving their peristaltic activity and proper elimination. The constant strain of gravity on the abdominal organs is reversed and fresh blood circulation ensues.

The abdominal organs, which are loaded with venous blood in the erect position every day, get relief from the congestion, and fresh healthy blood nourishes the villi in the walls of the intestine. Hence, absorption of food is better. The nerves supplying the abdominal organs get relief from the erect posture, and feel light and refreshed after Head stand. Fissures and piles heal well. As the liver receives better venous flow, the cardio-pulmonary circuit is well exercised. Any tendency to hernia of the abdominal or pelvic organs is checked. Inverted asanas can, upto a certain stage, help correct displaced organs.

Reproductive system The circulation to the various parts of the male and female genital organs is well toned up due to the inversion. The tendency to atrophic changes is retarded. Congestion in the prostate in the elderly male is prevented. Dysmenorrhoea is relieved by regular practice of inverted asanas as they ‘dry’ the system every day so that little congestion occurs in the uterus. It is not true that once the body is brought to the erect position, the blood flows down to the uterus. Our body cells have their own intelligence, independence and memory. Once a certain kind of stimulus is given to them every day, the effects remain in the system.

Scan 5Blood flow in Head stand in the ophthalmic vein (above) and the ophthalmic artery.

Since rest is given from the prolonged congestion, the sluggish cells get relief, venous return is better and circulation is not dull. Inverted poses are like a churning stone where the flow is kept active. The nerves of the uterus get rest so that their vaso-constrictive action on the blood vessels is effective. This prevents excessive menstrual discharge. Variations in head stand remove pelvic congestion and prevent recurrent pelvic infections. Inverted poses prevent the formation of fibroids as stagnation of circulation does not occur. Conditions of prolapse of the bladder and uterus due to poor muscle tone are greatly alleviated by these asanas. Stress incontinence during menopause is relieved by the variations. During pregnancy, the practice of inverted poses is very beneficial for both the fetus and the mother. The mother gets relief from the excess venous congestion in the legs and the utero-placental circulation is kept toned up. The baby and its circulation are well exercised in utero. There is no

danger if the right method is adopted.

Eye, ear, nose and throat The poses enhance and preserve blood flow to the ears, eyes and pharynx. Age-related atrophy of these areas does not occur. Tear gland secretions do not dry up. Degeneration of the retina does not occur with aging as normally happens. Allergic rhinitis (uncontrolled sneezing bouts provoked by any stimulus) and chronic mucoid sinusitis are cured. Recurrent sore throats are prevented as the poses pool the blood in those areas, bringing healthy immune cells to remain there.

Nervous system All inverted poses relax the sympathetic drive, and the hustle and bustle in the sympathetic system is removed. The sympathetic drive being relaxed, vessel tone and muscle tone are optimised. Relaxation occurs in the neurons throughout the body. Sirsasana is superior to sleep as it relieves insomnia by giving rest to the nerves. In Head stand, the cerebral cortex (from where the cortico-spinal nerves which are responsible for voluntary movements of the body originate) is well fed with blood. Age-related degeneration does not occur. The pose also acts on the ascending reticular activating system of the medulla (which is a point where many nerves crisscross) and thus gives the practitioner great mental alertness by resting those nerves. As inverted poses reduce the sympathetic tone, high blood pressure is controlled; particularly by half Halasana and Viparita Karani, where the excess sympathetic drive is reduced greatly. Energy flows as the nerves are given rest. Hence, their excitability is better. Niralamba Sarvangasana and half Halasana are valuable in this respect. The excitability of the neuron varies inversely with the activity of the system. In patients with high blood pressure, exhaustion, fatigue, and so on, the neurons tire out due to excessive activity. Recovery is needed. Asanas pose and repose the nervous system. During repose, the adjustments made in the asanas to relax the nerves provide the de-stressing mechanism. Energy is regained. Many patients feel like sleeping when practising some asanas. This is due to nervous exhaustion. This means the body needed the rest. Inverted poses (particularly Head stand) are a cure for migraine headaches as they prevent the neurocirculatory connections from turning chaotic. The uncontrolled shrinkage and dilatation of the blood vessels, which are the main features of the disease, are controlled and abolished with regular practice. During an attack, levels of certain chemicals in the brain, like serotonin, are lowered due to nervous exhaustion. Asanas give rest to the brain so that the chemicals are secreted. All areas of the brain are rested. However, forward bends are to be practised before head stand to tone up the circulatory system in a gentle manner. Rest is given to the neuro-muscular parts of the lower limbs. These feel stronger after the asanas are done because of relaxation to the nerves which innervate the muscles of the legs. The anti-gravity effect of the inverted exercise makes the nerves ‘light’. Recovery is good and their function is better. In this discussion, circulatory changes have been described with the nervous system as the toning up

of circulation depends greatly on a healthy state of nerves.

Endocrine system In Sirsasana, the neuronal connections between the pituitary and the hypothalamus are regularised and preserved. The pose cools these areas and soothes them. One can actually feel a cool sensation on the face which is probably due to the temperature regulating centre of the hypothalamus being made to send its sensations to the skin. Age-related neurological dysfunction does not occur in these areas. The thyroid and parathyroids are squezeed in Shoulder stand and Halasana due to the chin lock. This massages the glands, improving their blood supply. The poses initially soothe the thyroid; later the effect is stimulative. The adrenal glands are given rest and then energised. Values of certain parameters like plasma glucose, insulin, cortisol, growth hormone, C-peptide and glucagon change very minimally from a resting basal level. Yet, one emerges feeling very refreshed — probably due to better blood circulation and oxygenation. The cellular reserves of the glands are not exhausted by practising yoga in spite of the body having been exercised. The sensitivity of the complex neurohormonal mechanisms is well maintained. The conscious rest given to the sympathetic nerves in asanas is the mechanism by which recuperation occurs. As the neuro and endocrine systems are in anatomical connection, toning of one affects the other. Age-related atrophy of the cells in the endocrine glands does not affect the practitioner of inverted poses.

Musculo-skeletal system Cervical and dorsal spinal muscles and vertebrae are strengthened; deltoids and trapezius made stronger. Balance, grace and agility are developed. All parts of the body are strengthened due to the varied stresses and strains placed on them by the different shapes of the inversions. Regarding proper timing of these poses, Head stand, Shoulder stand and Halasana can be done for up to 20 minutes without ill effects. A minimum of five minutes is essential for chemical and mechanical benefits. Individual guidelines are important. Props help to prolong retention time. Patients with any kind of medical problem can practise these poses after due preparation; even hypertensives, as blood pressure does not increase in the brain (if clinically controlled by medication).

Forward bends (seated) Some of the forward bending asanas are Janu Sirsasana, Paschimottanasana, Ardha Baddha Padma Paschimottanasana, Triang Mukhaikapada Paschimottanasana, Parivrtta Paschimottanasana, Urdhva Mukha Paschimottanasana, Upavishta Konasana, Baddha Konasana, Pavana Mukta Virasana and Kurmasana (see illustrations, page 310). Yogis have watched animals and understood the benefits of assuming a horizontal posture in a conscious manner. When we are tired, we assume a horizontal posture. The nerves recuperate. The yogi consciously assumes such positions which have specific effects on the nervous system and the flow of energy.

At times of laboured breathing, we instinctively assume a bent posture. This gives relief. Asthmatics, when they suffer breathlessness, have to bend forward to rest the body. So, specific postures induce specific changes to the internal organs and the nervous system. The effects of forward bends on the various systems are described below.

Cardio-vascular system The cardiac chambers are compressed and massaged. Rest is given to the heart though the body is being exercised. Animals have a horizontal posture. Their heart is placed along the line of the spine. There is no strain on the heart to pump the blood against gravity. Exhaustion does not occur easily in the horizontal position. Hence, these poses are very helpful to prevent strain on the heart. As the spine is placed in a horizontal position, the elevated blood pressure is controlled in essential hypertension. This is due to the de-stressing of the pressure regulation centre in the frontal brain and the hibernation of the senses in the pose, producing withdrawal of the mind. The entire brain and mind are decompressed in these asanas. The over-drive of the sympathetic nervous reflexes is reduced, if forward bends are practised. The stretch induced to the sympathetic chain along the vertebral column feeds great energy into the system. The pulse rate and blood pressure reduce in a normal as well as in a hypertensive individual. The peripheral vascular resistance also diminishes. As the cardiac plexus is rested in forward bends, one feels invigorated. The vascular tone of the blood vessels reduces, and at the same time, certain areas are massaged. In certain other areas, as in the spinal muscles, the blood flow is enhanced.

Respiratory system The frontal lungs are flexed. The posterior surface of the lungs is stretched out. The intercostal muscles are well exercised and made elastic. This is something that seldom happens in day-to-day life. The anterior surface of the lungs is compressed and toned up. Due to the restricted space, the anterior fibres of the lung are well exercised by having to learn to breathe in a smaller compartment. The reverse occurs in backward bending exercises. The diaphragm is well massaged and toned up. As breathing is restful, the heart is rested. The respiratory rate reduces due to decrease in sympathetic stress.

Uttihita Trikonasana

Parivrtta Trikonasanna

Uttihita Parsvakonasana

Parivrtta Parsvakonasana

Virabhadrasana III

Adho Mukha Svanasana

Ardha Chandrasana

Prasarita Padottanasana

Sirsasana

Parivrttaika Pada Sirsasana

Sarvangasana

Setu Bandha Sarvangasana

Halasana

Badda Konasana

Skandasana

Upavishta Konasana

Janu Sirsasana

Paschimottanasana

Supta Padangusthasana.

Marichyasana III

Yoga Dandasana

Ardha Matsyendrasana I

Ardha Matsyendrasana II.

Bakasana

Galavasana

Kukkutasana

Parsva Kukkutasana

Eka Pada Basasana

Pincha Mayurasana

Eka Pada Raja Kapotasana

Eka Pada Galavasana

Natarajasana

Urdhva Dhanurasana

Dwipada Viparita Dandasana

Hanumanasana

Abdominal system The quietening of the senses soothes the salivary glands. Forward bends cause flexion of the abdominal organs, which are compressed and massaged. This improves their digestive, absorptive and excretory functions. These asanas help massage the colon, thus eliminating waste matter properly. The stimulative effect of compression increases gastric acidity. This arouses appetite and hunger as the vagus nerve is massaged. The adrenal glands are rested. The medulla of the kidneys are compressed and the functions are toned up. The pancreas and gall bladder are toned up. Regular practice of forward bends prevent benign enlargement of prostate due to constant pressure of the heel on the gland in the Ardha Baddha Padma pose, even though there is a hormonal basis to the enlargement. The pelvic organs function better due to internal massage which works along anatomical lines. Just as the skeletal parts of the body are used in adduction, abduction, flexion or extension, asanas work likewise. For example, Janu Sirsasana flexes the abdominal organs with a rotational force. Paschimottanasana flexes the organs in a linear manner. Parivrtta Janu Sirsasana works by circumduction which is a combination of flexion, adduction, abduction and extension. By such sophisticated methods, the organs are stimulated or made tranquil. Yoga is the only exercise that provides for tranquillity of the inner organs. They, therefore, function healthily for longer periods. Certain asanas like Supta Baddha Konasana and Upavishta Konasana give relief to dysmenorrhoea. Delivery becomes easier due to an elastic pelvic floor. Supta Baddha Konasana gives relief from nausea associated with pregnancy. It also prevents the separation of the pubic bones due to the weight of the baby. During pregnancy, concave forward bends are very beneficial to the mother to tone up the

lumbo-sacral spine. The blood flow to the fetus is better in these positions and the uterine sac is rested.

Nervous system The frontal brain (the seat of intellectual activity) is quietened, and the blood flow to the brain (confirmed by Doppler flow) is regularised. There occurs a "decompressive" effect on the spinal brain which relieves nervine stress, chronic headaches and eye pain; the mechanism being neurocirculatory in origin. The exercises give complete rest to the sympathetic nervous system. This has its effects on other systems; for example, the immune system functions better as stress is reduced. The effect is one of `conscious sleep’. Rejuvenation occurs faster. Another peculiar effect of forward bends is that of mental alertness. These asanas help the brain become razor sharp and free from fatigue. The poses have a psychosomatic effect. The yogi withdraws to the inner world. Stress is released from the organs of perception. This, in turn, relaxes the senses and refreshes the system. The mind is disconnected from the organs of perception. In a way, this is preparatory to pranayama practice as the practitioner learns to keep the mind still in the pose. If this stillness of mind is not maintained in the pose, refreshment is not perceived. Regular practice keeps one from falling asleep at the end of a long day.

Endocrine system The hormonal status does not fluctuate much from the baseline. All endocrine glands are soothed by the practice of forward bends. As the mind is made tranquil the nervous system is quiet. This, in turn, soothes the glandular system. In these asanas the neuro-hormonal circuitry is kept very sensitive and fresh. The adrenal glands derive maximum benefit due to the soothing action of the pose. The adrenal glands are profusely innervated with sympathetic nerves and if this system is rested, the glands do not suffer exhaustion and the cellular contents are preserved. More energy is available for daily work. It is interesting that a regular practitioner notices the difference in energy levels if he or she omits forward bends even for one day. Metabolic activity slows down, providing rest to the thyroid gland. The entire body hibernates in the practice of forward bends. As the cellular pace is quietened, inner wasting of the body is prevented as one grows older.

Musculo-skeletal system The joints between the ribs and the spine on the posterior aspect are toned up. All posterior intercostal muscles are made very elastic. The intervertebral joints are stretched and strengthened. As they maintain their elasticity, degeneration of the spinal joints does not occur. All parts of the spine are made stronger. The ligaments of the spinal column are strengthened. Nutrition to the disc is maintained even in old age. As the spine is supple, low back problems of mechanical nature do not

occur. The sciatic nerve is decompressed in its course along the leg, averting sciatic pains. In forward bends, the blood is made to circulate well in the muscles and away from the central spinal area. The blood flows in a linear manner along the centre of the spine. All spinal muscles are stretched and soothed by excellent blood flow. These are good poses to combat osteoporotic pain. The hamstrings are kept healthy and elastic. Circulation in the legs is toned up due to the stretch on the hamstring muscles. The Achilles tendon is kept soft and supple. The arches of the foot are well stretched, preventing fatigue pain in the feet. The gluteal muscles are well stretched along with the sacro-iliac muscles. The entire back feels warm and soft after a good five minute stay in these poses.

Reproductive system The asanas help control physical and mental sexual urges as the frontal brain is soothed. The male external genitalia are massaged and their functions well maintained. Baddha Konasana and Upavishta Konasana quieten the physical tension in the external genitalia, controlling the physical drive. These poses prevent recurrent white discharge in women. A physiological contraction is created in the uterus so that the capacity of the organ to dry up after a menstrual flow is easy. Forward bends are useful to regulate menstrual flow. They massage the fallopian tubes and ovaries, and promote healthy circulation. They prevent the formation of fibroids. Baddha and Upavishta Konasana increase the blood supply to the pelvic organs by a healthy stretch to those areas. The two asanas make the pelvic floor elastic, facilitating easy delivery. Practice of forward bends, particularly Ardha Baddha Padma Paschimottanasana, creates pressure on the prostate gland, preventing benign enlargement. As one ages and physical activity declines, the amount of androgen needed to maintain cellular growth and muscle mass diminishes. It is possible that in this situation testosterone can get continually converted to dihydrotestosterone, particularly in the prostate, causing prostatic enlargement. If regular physical activity is ensured, more androgenic production of testosterone may occur maintaining healthy body growth and activity. It has been observed that in men who are very active physically and ensure regular exercise every day, the incidence of enlarged prostate is less than in others. A timing of five minutes in all forward bends is essential. They can be held for a period of even ten minutes. The entire repertoire of forward bends can take an hour to complete. Props can be used. During pregnancy these poses are avoided as the baby would be pressurised, but concave positions can be safely done and, in fact, strengthen the spine.

Asanas in a seated position These are Padmasana, Baddha Konasana, Baddha Padmasana, Akarna Dhanurasana, Kandasana, Virasana, Supta Virasana, the Eka Pada Sirsasana cycle, Mula Bandhasana and Hanumanasana (see illustrations, pages 308, 309). Many of us do not sit erect, thus damaging the alignment of the internal organs and the skeletal system. Proper flow of blood to the internal organs is restricted. In the long run, the organs suffer premature aging. Poor posture causes build up of pressures at various parts of the muscles and bones, leading to

chronic pain. Degenerative disease is the result. The mind too suffers from poor posture. When we sit erect, the mind has to remain alert. The mind, in turn, receives feedback from the body and corrects defective posture. Let us see the effects of the seated postures.

Heart and circulation The erect posture favours better mechanical function of the heart. In the Eka Pada Sirsasana cycle, the heart is compressed. Circulation is optmized to all parts of the body — in Virasana, to the digestive organs; in Mula Bandhasana, to the pelvic organs; in Supta Virasana, to the heart and lungs and abdominal organs; in Kandasana, to the abdominal organs due to the internal massage; in the Eka Pada Sirsasana cycle, to the back of the spine; and in Hanumanasana, to the pelvic and genital organs, and the legs.

Respiratory system Due to the erect posture, the ribs and intercostal muscles are well toned and breathing is easier. The dorsal spine is elasticised and this contracts the back of the lungs. The body is prepared for pranayama. The Eka Pada Sirsasana cycle massages the front and stretches the back of the lungs. These movements are useful for older people who may find other postures difficult.

Abdominal and pelvic organs Supta Virasana gives relief to patients suffering from non ulcer dyspepsia. This asana is invaluable, especially if done after food with the support of pillows. Gastric motility is regularised and blood supply to the mucosa is improved, so that digestion is better. In Baddha Padmasana and Kandasana, the pressure of the heels on the nerve plexuses tones up the functioning of the abdominal organs. Peristaltic activity is improved. In the Eka Pada Sirsasana cycle, the abdominal organs are contracted and function better due to the massage given to them. Upavishta Konasana in the erect sitting position and Supta Baddha Konasana are very valuable for patients with back pain and cramps in the abdomen during the menstrual cycle. Baddha Konasana relieves and abolishes the back ache of dysmenorrhoea, if one practices it regularly. Suppleness is provided to the pelvic organs so that they do not wear out easily. The toning up of the pelvic organs is very useful in pregnancy. Labour pains decrease, and spasms start functioning. Delivery takes place with ease.

Locomotor system All seated postures give elasticity to the hips, knees, ankles and groin muscles. Poses like Padmasana, Virasana, Supta Virasana relieve arthritis of the knees and ankles, plantar fascitis (where the tissues on the sole become inflamed due to overweight and wrong usage), calcaneal spurs, varicose veins, and other conditions. Hanumanasana tones the entire neuro-physio-venous system of the legs. It also prevents arthritis of the hips and knees, and peripheral vascular disease. Kandasana,

an advanced pose, keeps the ankle, hip and knee joints completely flexible as one grows older. Baddha padmasana gives elasticity to the shoulders, knees and ankles. Akarna Dhanurasana gives elasticity to the hamstring muscles and hip joint. The Eka Pada Sirsasana cycle is unique in that one leg is placed on the back of the neck. This produces total elasticity of the hamstring muscles.

Nervous system All seated postures keep the spine steady and, hence, the mind becomes calm. Conversely, a calm mind inculcates a stable posture. As the spine is kept erect, it is easier for blood to flow to the brain. These postures improve proprioceptive skills and refine blood flow to different areas of the spinal nerves. As there is intellectual stability, withdrawal of the senses is easier. Hence, these postures are useful for meditation. The timing varies with the kind of pose practised. For example, Padmasana can be practised even for an hour. Baddha and Upavishta Konasana require a minimum of five minutes. The poses in the Eka Pada Sirsasana cycle can be done for a couple of minutes each. Supta Virasana can be done for even fifteen to twenty minutes. Asanas like Kandasana and Mula Bandhasana can be held for a couple of minutes only due to their intense nature. Most of the poses can be done safely during pregnancy, with careful guidance.

Twisting poses The twisting poses — Bharadwajasana, Marichyasana, the Ardha Matsyendrasana and the Pasasana cycles — are unique (see illustrations, page 309). We hardly rotate our spine in normal life. This makes the muscles stiff like a starched cloth. At birth, the baby rotates to make an exit, and after this man never rotates his spinal column to the extent that is beneficial to the body. Yoga has devised twisting asanas in many patterns, all of which benefit different parts of the body. They promote the health of both the external and internal body. Stiffness in the spinal region, which prevents the proper circulation of nervous energy and blood flow to the nerves of the spinal cord, is fully banished. Many of our activities involve asymmetrical usage of the muscles. While watching television we often turn the body to one side. Most of us turn the spine to the same side to reverse a car. In this manner many activities can be shown to be one-sided in execution - some unconsciously and others consciously. Yoga teaches us to be better aware of our body positions and movements. It is essential to recognise the pattern of using our body in everyday life and institute corrections. Twisting poses teach us alignment and the importance of a healthy spine and inner body. Not that other poses do not do this; but twisting asanas are distinctive in that every articulation between the spinal vertebrae is used in a calculated manner. Let us study the effects.

Cardiovascular system The poses alternatively squeeze and stretch the lateral walls of the heart. They compress and stretch the thoracic cavity, ensuring excellent cardiac function. The major blood vessels in the thoracic cavity are well massaged. Cardiac contractility is well maintained. The heart is abducted and adducted in the process of massage. The abdominal and pelvic diaphragms being elasticised, better circulation of

blood takes place throughout the body.

The lungs The thoracic spine is made elastic. The intercostal muscles are kept soft and supple. The diaphragm is made healthy and excellent lung expansion follows. The lungs are alternatively squeezed and expanded, maintaining their vital capacity. Breathing is faster in the twist in the initial stages, and this conditions the lungs to adjust to a constricted thoracic cavity. All such actions prevent senile degeneration of the cells of the lungs. Venous return is healthier and thoracic arterial and venous circulation is excellent.

Abdominal and pelvic organs Twisting postures improve blood circulation in the pelvic and abdominal organs by alternatively squeezing and rinsing them. While one side of the abdominal organs are squeezed, the other side is stretched. The circulation of body fluids is thus well maintained with these asanas, keeping the inner body soft and supple as that of a child. Abdominal and pelvic disorders like dyspepsia, dysmenorrhoea, hernia, functional disorders like constipation, are all kept at bay. Twisting poses are a combination of flexion, rotation, adduction and abduction. Different parts of the body are worked in these poses. In Marichyasana, for example, the liver is squeezed more than in Bharadwajasana. In Pasasana the movement is less of flexion, more of extension and rotation. Therefore, the spleen is squeezed more than in marichyasana. In this manner the organs are worked on different lines. During pregnancy these movements, when carefully done, create room for the uterus to expand comfortably so that the baby can move freely. Women who practice yoga correctly do not feel uncomfortable with the kicking movements of the baby. As the emerging spinal nerves are stretched and toned up, all the innervated organs are kept healthy. The prostate does not enlarge if one does twisting poses regularly. The stomach, ileum and colon are massaged and this improves digestion, absorption and elimination. One of the best felt effects of asanas is that of the twisting poses on the gastrointestinal tract. The gall bladder is squeezed and bile milked out. This ensures better fat digestion. The squeezing effect can easily be demonstrated by ultrasound. This also prevents stagnation of bile and consequent gall stones. The ancients maintained that twisting poses are useful for good digestion. This probably relates to the ability to ensure fat digestion for, if fat is improperly digested, the system becomes dull; carbohydrate and protein are digested rather than fat. With practice of twisting poses, cellular longevity is promoted. The churning action of the stomach is well maintained even in old age. The cells in the ileum are kept soft and micro cellular functions are preserved. Intestinal villi function and lymphatic circulation are preserved and stimulated. Due to softness of the cells, water regulation of the colonic contents is good even in old age. This prevents constipation. Transit time of intestinal contents is regulated. The kidneys are rinsed with blood. Renal blood flow is preserved as atherosclerotic changes in the major arteries of the abdominal cavity are inhibited. The pancreas is massaged and this prevents atrophy and helps in certain diabetic states. As the abdominal muscles bear receptors for insulin,

toning of these muscles and maintaining the vascularity helps in maintaining the insulin sensitivity of the receptors.

Locomotor system All these poses relieve spinal, hip and groin problems. The intervertebral joints are made elastic; compression does not occur, nor does the disc herniate. The disc herniates only if the spinal muscles are rigid. In yoga, elasticity is given to the annulus to bear rise in intradiscal pressure. Even if the disc herniates, relief from compression of the spinal nerves can be given by pushing the disc into place and strengthening the annulus fibrosis. The nerve roots at the level of the foramina are stimulated. Blood circulation to the spinal nerve root is stimulated. The nerve roots are massaged. Adhesions are prevented. Circulation to the entire spinal cord is enhanced and a massaging action is predominant. Hence the neural centres in the spinal cord remain healthy. The chakras are stimulated. The paraspinal muscles remain soft and supple because of better blood flow, preventing mechanical low back disorders. The spinal and the hamstring muscles become stiff with age and the range of movement of the hip joint and the spine is highly reduced. On account of this, when a person bends forward, the pelvis is unable to rotate on the hip joint though spinal movements continue. The muscles snap at the lumbar region. The disc ruptures due to increased tension placed on it. However, if a person with flexible hip joints bends forward the pelvis rotates completely, allowing the spine to stretch forward. Spinal length is thus maintained in all its curvatures without the lumbar region becoming convex as would occur if the hamstrings were very stiff. Hence, in yoga, the entire spine and the legs are kept completely elastic so that no spinal problem can set in. The asanas prevent internal derangement and calcification of the shoulder; pain in the shoulder blades disappear; osteoarthritic hip joints are benefited. Asanas help prevent tears and sprains of the inner groin muscles. The groin muscles and ligaments are kept flexible. Arthritic disorders of the knee and ankle are prevented. Twisting poses can be held for a period of one to two minutes or even three, if possible. Pasasana is highly beneficial to prevent back aches. If this is done effectively, mechanical back aches disappear for ever. This asana gives excellent elasticity to the ankles and can be held for a period of two to three minutes. The practice of these poses during pregnancy is modified from month to month as the sac enlarges. They can be safely done by a pregnant woman who is otherwise medically healthy, i.e., without any complications of pregnancy.

Balancing asanas There are numerous asanas in this category — Bakasana and its cycle, Galavasana and its cycle, Kukkutasana and its cycle, Koundinyasana and its cycle (see illustrations, pages 310, 311). They are distinctive in that we learn to bear our own body weight without any gadgets. As we grow older, it is essential that we maintain a certain litheness and agility in our movements. This can be achieved by simple balancing poses like Uttihita Padmasana and Bhujapidasana. The muscles are used in a

peculiar way to balance in these poses. The antigravity action leads to a controlled stretch and contraction during movement to the final position. As the yogi uses his own body as a weight and counter weight, internal arrangement of the organs in relation to the skeletal system is possible. Such concepts do not exist in other systems of exercises.

Locomotor system The effects of balancing asanas are most perceivable in this system. All these asanas serve to strengthen the arms, wrists and the shoulders. The body acts as weight and counterweight in these asanas. The deltoids and latissimus muscles (the so-called ‘wing’ muscles) are strengthened. All the tendons in the arms are toned up. The bones of the forearm, upper arm, shoulder blade and the entire vertebral column are made stronger. The bones in the spinal column are massaged as a compressive load is applied. Bone remodelling is excellent as the load on the bones is precisely calculated. Hence, this strengthens the bones even though the practitioner does not lift heavy weights as in body building. No portion of the body is neglected as usage is in different geometric patterns, unlike in other systems where the maximum load repeatedly uses the same areas of the body. For example in weight lifting, the thigh bone hypertrophies more than the tibia and fibula as it bears the brunt of the load.

The heart and circulation The chambers are massaged and the major arteries in the abdominal cavity are compressed, allowing better circulation of blood in these areas. Due to the calculated load to the cardiac system, effort tolerance is built up. The pulse rate and blood pressure have a negligible increase.

The lungs The frontal lungs are compressed and the back portion stretched. Due to the strain, effort tolerance increases. Yet, breathing does not become laboured as in aerobic exercises. As the thoracic cage is compressed, internal massage occurs. The dropping of the body into Urdhva Dhanurasana after the completion of balancing poses stretches the lungs to the maximum, increasing the intake of oxygen and invigorating the system. The body becomes warm in a short period.

Abdominal organs The abdominal organs are contracted and toned up. Constipation is eliminated and flatulence is relieved. The internal massage in these poses is far more intense than forward bends, though only for a short period as the poses are not retained as are forward bends. The floor of the bladder, uterus and prostate are toned up. The functions of the digestive system are well maintained in the long run. Balancing poses can be held for as long as is possible by the practitioner.

Back bending asanas These include Bhujangasana, Dhanurasana, Urdhva Dhanurasana, Viparita Dandasana, Kapotasana,

Mandalasana, Vrschikasana, Ganda Bherundasana, Raja Kapotasana, Viparita Salabasana and Natarajasana (see illustrations, pages 311, 312). These asanas are most intensive. It requires great mental and physical stamina to practise them. In normal everyday living, we may bend forward, but we never have the opportunity to bend backwards — except when obliging someone! Hence, one finds it difficult to train the body in these positions. Props help the beginner as well as the patient. In fact, many healthy beginners benefit from using props to make the body flexible for these poses. Sri B K S Iyengar has innovated a variety of props to learn the advanced postures. These postures have a wide range of benefits for body and mind. Without a doubt, they delay mental and physiological aging. Unless the asanas are done, it is difficult to realise this. No form of aerobic exercise is needed if back bends are practised.

Cardiovascular system Wonderfully geared for the cardiac system, these asanas help to prevent atherosclerotic changes in the coronary arteries. If done from childhood, no atherosclerosis can occur in the coronary vessels. In cases where the vessels are blocked, either partially or fully, these asanas maintain free passage in the vessels; or, in certain cases, reopen the vessels so that further reduction of blood flow does not occur and fresh blood is re-introduced to the starving tissues. As the heart is the centre for circulation, maintaining it ensures a healthy state of circulation throughout the body. Circulation is speeded up as the sympathetic nerves are stimulated, and one feels warm immediately after a single pose is executed. A bypass surgery can be avoided in many cases if yoga is started early enough. In my experience, patients with triple vessel disease have avoided surgery by resorting to asana practice. The benefits would depend on the individual merits of each patient. The arch of the aorta is expanded by these asanas. The arch of the aorta works as a pump pushing the blood into the coronaries. As age advances, this elasticity is lost; it is preserved by these asanas. Blood is pushed into the coronaries due to more space being available for the intra-thoracic organs to expand and contract. The nature of the stimulus is due to the geometry of the pose. One can feel the blood flow increase in the intrathoracic organs. As the chest opens up in back bends, intra-thoracic blood flow increases. This is due to the distensibility of the low pressure pulmonary circulation to accommodate this. The principle is fairly straightforward: stretching any area improves blood flow. Asanas teach one the method to stretch the very organs themselves. Back bends help extension of the heart. Such a stimulus is not possible in other systems of exercises. If the heart is shrunk, the asanas help open the cavity. If dilated, the cavity is made to compress. The extension of the chest cavity and the linear manner of stretch provide for such changes in shape of the cardiac chambers, resulting in a double action mechanism on the body. This results in healthier pumping capacity of the heart muscle. The blood circulation in our organs is stimulated due to the stretch or contraction given to them. So healthy functioning of the organs continues, even as one grows older. The more difficult back bends have better effects on coronary status. Viparita Dandasana, Urdhva Dhanurasana and Kapotasana are invaluable. If one progresses to enhanced practice, with or without

props, the heart and its vessels can be kept clean. It is well known that blocks are prone to form in areas of low velocity blood flow in the body. Never are the intrathoracic organs so stretched in other systems of exercise and, that too, so anatomically. This increases the rate of blood flow which is also a factor apart from the ease with which blood flows due to the stretch.

Respiratory system If forward bends provide for flexion of the anterior lungs, back bends cause extension of the anterior lungs and flexion of the posterior lungs. As one grows older, the respiratory system becomes stiff and sluggish. This is easily observable when one becomes breathless on climbing a flight of stairs or even walking on level ground. This is because the muscles of the thoracic cage become stiff and inelastic. The fibres of the lung become rigid and not all the cells of the lung function. Secondly, 95% of human beings often breathe in a shallow manner. Though medical science accepts this decline in lung capacity as part of the normal aging process, yoga does not; it offers a solution. The vital capacity of the lungs can be kept up throughout life by these asanas. Back bending asanas maintain elasticity of respiratory muscles and the oxygen-carrying capacity of the lungs is unaffected. Every bronchi, bronchiole and individual alveolus is made to open completely. More oxygen is drawn in during the practice of these poses, but extra usage is prevented. Efficient distribution to the tissues occurs, enriching cellular longevity and vitality. Thus energisation of the system occurs. These asanas are far superior to aerobic exercises where, though intake of oxygen increases, usage also increases. In contrast to forward bends where the lower and middle posterior portions of the lungs are toned up, in back bends the anterior surface of the lower, middle and upper lobes are toned up. The human lung thus has a tremendous capacity to stretch. Elasticity of the intercostal muscles and ribs are maintained. The thoracic organs are squeezed, maintaining the softness of their cells. According to yoga, breath is life and life is breath. If breathing is retarded, ill health occurs; hence great importance is given to toning up the lungs. Healthy circulation of immune cells which prevents pulmonary infections is valuable, especially in the geriatric age group. Even if infection occurs, recovery is often faster. If deep breathing is done in these asanas, mucous plugs are removed, narrowed bronchioles are opened, and a free flow of breath is maintained. It is thus very useful for giving relief to a variety of lung disorders like cystic fibrosis, asthma and chronic bronchitis. Persons who practise these poses never feel breathless even with severe exertional activities.

Abdominal and pelvic organs The abdomino-pelvic organs are well extended, yet squeezed in a linear manner. This improves their blood supply. The abdominal part of the aorta is well stretched and blood flow is made easier. All branches of the aorta have enhanced blood flow. The walls remain elastic. The portal system of circulation is well stimulated and the liver receives better blood flow. The inferior vena cava is stretched, improving venous return and preventing venous congestion in the abdominal and pelvic organs. Any tendency to prolapse of the organs is corrected. Due to the stretch of the vagus nerve,

acidity decreases and dyspepsia is relieved. The gastric cells are quietened. Back bends reduce excess hunger. The liver, pancreas and gall bladder get a better supply of blood. The intestines are stimulated and motility enhanced. Blood supply to all the abdominal organs is maintained throughout life. As the villous cells are preserved, digestion, absorption and assimilation are maintained. Lymphatic circulation in the villi is maintained. Ischaemia of the bowel never occurs as the asanas maintain blood flow to the organs. The kidneys are squeezed and their functions are toned up. Due to the flushing effect of the asanas, blood supply in the kidneys is maintained (demonstrable by ultrasound) even in old age. Their role in diabetic nephropathy is most useful if the asanas are started at the earliest, when the first pathological change has occurred. Microvascular changes of diabetes cannot occur, if asanas are practised regularly. Just as the quality of the air in a drum depends on the shape of the drum and the tension of the overlying skin, back bends and their variations impart to the abdominal organs the quality which maintains their health. These asanas stretch and contract the diaphragm so that the valves in the stomach and the muscular sheets of the diaphragm are toned up, preventing hiatus hernia. The muscles of the abdominal wall are well toned, preventing the formation of other types of hernias.

Reproductive organs Extension of pelvic organs occurs in back bends. Prolapse of the bladder and uterus are prevented by back bends as the organs are lifted up. Back bends help arrest excess menstrual flow due to the upward sucking action of the pose on the organ. Painful periods can be averted (refer chapter on dysmenorrhoea). Atrophy of tissues during menopause is prevented, and the muscular tension of the supports of the various organs is preserved. This retains every organ in the correct anatomical position. In the male, the prostate is stretched, its blood supply improved. During pregnancy, the practice of these asanas helps generate more room in the abdominal cavity to allow the uterus to expand freely. The baby derives better blood supply as the placental circulation is stimulated. Chances of reduction in fetal oxygen supply are prevented. Abortions can be prevented (refer chapter on pregnancy). Problems like hiatus hernia, heartburn, heaviness in the abdomen during pregnancy can all be avoided by practising these asanas. Modification of the poses with each month of pregnancy is a must. The physical sexual urge is stimulated by these asanas as the relevant nerves are energised. Stimulation of the genital nerves provides for a healthy erection in the male. The sexual drive also lasts longer as the mind is stimulated. In the female, the contractile capacity of the vagina and perineal muscles are enhanced.

Endocrine system The endocrine glands are stimulated in contrast to forward bends. The effect is immediate and can be felt. The adrenals are ideally stimulated by back bends. The pituitary, pineal and thyroid glands are also invigorated. Hence, energisation of the system is healthy, enhancing cellular functioning and

metabolism. Insulin sensitivity of the tissues is well preserved. As the asanas are intense in nature, the metabolic rate of the body is raised during practice. Even this can be controlled to the exact degree needed.

Nervous system The tension developed in the skull, muscles and mind due to the geometric shape of these asanas invigorates the central and autonomous system. Pulse rate and blood pressure are stimulated, energising the system. The effects may appear similar to aerobic exercises, but there occurs minimal wastage of cellular reserves. This is the major difference. Vitality in old age is preserved. A back bend that can invigorate the system though it is a dynamic pose is Viparita Chakrasana. The various centres in the brain are stimulated, increasing mental alertness. It is important that the mind should remain quiet and perception has to be from the state of silence; particularly for back bends, as careful observation is needed to understand the great range of extension in these asanas. Due to the stretch, intercostal neuritis (inflammation of the nerves in the intercostal space) never occurs. Costochondritis, which is a condition of inflammation of the junction of the ribs articulating with the breast bone, and is a common clinical problem, is prevented with regular practice of back bends. If the mind is tense, headaches are felt at once or, later on, exhaustion occurs. This is due to overstrain of the nerves. Back bends give the nervous system strength to face stress and disorders like blood pressure, head-aches, nervous exhaustion do not occur. Heat is generated in the nerves of the body, which is useful for persons living at high altitudes and in cold countries. Stimulation of all yogic chakras occurs in these poses. The areas occupied by the chakras are stimulated due to the intense stretch. The sympathetic nerve chain along the vertebral column is well fed with blood. While the nerves on the anterior surface of the body are stretched, those on the posterior surface are contracted. The anterior surface of the spinal column with its sympathetic nerves and ganglia is stimulated and fed with blood. As the nerves are well fed with blood and stimulated, their function of innervating the respective organs remains efficient. Electrical current can flow to the areas without blockage. As the inner vitality of a person is a function of the nervine condition, back bends preserve and impart this vitality due to the healthy chemical changes in the adrenal glands and central nervous system. These poses energise the body by stimulation in contrast to forward bends which energise the body by removing stress. Both kinds of effects are needed. The former toughens the body while the latter provides back up strength.

Musculo-skeletal system Back bends cause the blood to be sucked deep into the centre of the spine by virtue of their mechanical action. The entire anterior surface of the vertebrae on the spine is opened up. So arthritis, spondylitis and other degenerative changes of the cervical spine do not occur; nor does dorsal spondylitis, for the dorsal spine is kept supple. Vertigo due to cervical spondylitis is abolished as the

cervical curvature is remodelled. The muscles in the front of the body are stretched and those at the back are intensely contracted, making for strong spinal muscles. The posterior surface of the disc is strengthened preventing the annulus from rupturing. Nutrition of the disc is maintained as the surrounding tissues remain soft. The breast bone, ribs, shoulders, collar bone, upper arms and wrists are all made strong. The sacroiliac and lumbar muscles are strengthened. The hamstrings are contracted and massaged. This improves blood circulation in the legs. The thigh bone is stimulated due to the strain of lifting the body in poses like Urdhva Dhanurasana and Viparita Dandasana. The knee joints are made stronger as the muscle is made to lift the body weight in the asanas. The tibia and fibula become strong and load bearing is preserved. Osteoporosis of the skeletal system never occurs if such asanas are practised. Vertebral changes of decalcification are common in old age. Back bends prevent such effects due to the considerable load on the bones in executing the poses. Usage of the ropes in practice helps gentle learning without injury. Variations have greater effect. The Viparita Dandasana rack is a boon in this respect.

Ear, nose and throat (ENT) There is a special effect of these asanas on the ear. Disorders of the inner ear and balancing apparatus like Meniere’s disease, idiopathic tinnitus, vertigo, otosclerosis, etc., are relieved by these asanas. Circulation in the inner ear is enhanced. Proper vibration of the ossicles is ensured. In Meniere’s disease, the over-distention of the inner ear with fluid is regulated and the stability of the membranous labyrinth maintained by back bends. Edema formation is prevented and function is restored. In otosclerosis, the sound wave is not conducted to the inner ear due to lack of vibration of the bony ossicles. Back bends loosen the fixity of the bones in most cases, if diagnosed early enough. Here, it is important to understand that only if the poses can be executed well enough can the benefits be obtained. Back bends are advanced postures and, even if props are used, it may be difficult for the older patient to achieve the pose. Young persons with otosclerosis gain the maximum benefits. The advanced poses are difficult to perform and props are a great help. Minimum timing of a minute to two is essential in all back bends. The props help achieve more than maximum timing. Regular practice of back bends maintains the very life of the practitioner.

Pranayama It is difficult to describe pranayana. This word can be split into prana and ayama. It is physical, mental, spiritual and cosmic energy. All forms of energy are prana. Prana is usually translated as breath, which moves in the thoracic region and absorbs vital energy; yet, this is only one of its many manifestations in the body. Ayama means control. So pranayama is the science of breath control. It is a deliberate technique of inhalation, retention of breath, exhalation and the suspension of breath in exhalation. The movements of the thoracic organs include vertical ascension, horizontal expansion and a circumferential movement. Pranayama is (apart from the physiological connotation of harmony of breath) a psychosomatic science. It is well known that the psyche affects the soma and vice versa — the classical example being that of stressinduced peptic ulcers. Judicious use of the psyche produces a healthy soma. In pranayama, the mind and consciousness is withdrawn deep inside to the core of the being. This stabilises and optimises all functions of the body. Only in this quietude can energy levels of the body be harmonised. The five elements, the organs of perception, and the organs of action are coordinated. This actually means prevention and removal of disease. Pranayama must be practised only after a certain mastery in asanas has been achieved. This ensures healthy elasticity of all the organs and the respiratory muscles which make pranayamic breathing easier and more precise. Medically this logic is tenable. Patanjali has stated: "Tasmin sati svasa prasvasayoh gativichedah pranayamah" — "pranayama is the regulation of the incoming and outgoing flow of breath with retention" (Iyengar, op.cit., "Sadhana Pada", II.49). "It is to be practised only after perfection in asanas is attained." Nowadays it is common to see many yogic schools imparting pranayamic training to beginners. This should be avoided.

Physiology of pranayama Usually, we do not inhale and exhale deeply. Oxygen utilisation, though healthy, is not sufficient for the stress and strain of modern living. The science of pranayama teaches us how to reduce the respiratory and heart rate, while increasing the quantum of the oxygen drawn in and decreasing the outflow of breath. This can be as minimal as two or three cycles per minute. When the respiratory rate is thus lowered, the metabolic rate of the body also reduces. The body is brought to a state of temporary hibernation. All the cells are rested, and relaxation ensues. The sympathetic overdrive is reduced, with consequent energy conservation. In pranayama, the mind is kept attentive so that the rhythm of breathing is regulated. The frontal brain, which is the seat of intellectual activity, is made quiet. Complete neuro-physiological relaxation occurs. It is essential to dampen the excess sympathetic drive which exhausts the body in the long run. Just as the sympathetic nervous system is given rest in sleep, in pranayamic practice rest is induced consciously in a short period. Pranayama works directly to regulate the neuro-hormonal system which is the seat of energy in the human body.

There are many varieties of pranayama, each having different effects on the respiratory tract and the rest of the body. Equal and unequal stimulation is provided to different parts of the respiratory tree by virtue of different ratios of breathing patterns. Each has its own physical, physiological and biochemical effects on the body. Sitali pranayama soothes and reduces the body temperature, while surya bedhana pranayama heats the system, by stimulating the pingala nerve in the right nostril. Bhastrika pranayama heats up the entire system like stoking a furnace. Ujjayi pranayama relieves congestion in the throat and vocal cords and is very useful to the musician. All types of pranayama work on a sound physiological basis, either stimulating or soothing the cells. The respiratory rate, which is normally around 14 to 18 per minute, is reduced to the level of two to three per minute. This has tremendous consequences, especially for body metabolism. The entire system hibernates and cellular activity is quietened. Wear and tear at the micro-level is slowed down in all the systems in the body. The induced quietitude refreshes cells. This rest is far superior to even six hours of sleep. Let us discuss in detail the effects of pranayama.

Cardiovascular system Due to the constant change in the chamber size of the heart, the cardiac muscle wall is properly exercised. This is without strain. Complete filling and emptying of the chambers is ensured. The autonomic control of the heart rate is rested and the rate reduced. This helps in more efficient cardiac functioning, as the metabolic demands of the entire body are also reduced. Just as the skeletal muscle is toned up by exercise, cardiac muscle should also be toned up. Elasticity of the arch of the aorta is maintained, thus preserving and promoting coronary flow. As more and more capillaries are opened up, micro circulation is enhanced. Hence, an enhanced supply of nutrients to the cells occurs, increasing their longevity. All this happens without increase in pulse rate or blood pressure, in contrast to other exercises which exhaust the reserves of the cellular systems. Deep breathing reduces the sympathetic tone, allowing the vasomotor tone from the brain (which controls the calibre of the blood vessels and hence blood pressure) to reduce too. Better blood flow to all organs is the result. This is important for normal individuals as well as hypertensives. Even in a normal individual, the state of circulation is not one of free flow. Daily living causes accumulation of stress on the blood vessels, keeping them in a constricted state. This relaxes during sleep and rest. Hence, pranayama is useful for preventing hypertension and as a curative in such disorders. The most important effect is washing away free radicals which can damage the heart.

Respiratory system The concept of pranayama is often mistaken for deep breathing. In the latter situation, movement of breath is fast and forceful. There is no time for the cells of the lungs to get soaked in the inhaled oxygen. In pranayama, the movements are so slow that there is adequate time for every alveoli to soak in oxygen. The drawn in energy is also not allowed to forcefully exit from the system. That is the reason why exhalation is very slow. This gives time for the system to continue to absorb energy even during the exhalation phase. The trachea and bronchi, being like an inverted tree, serve to aerate the lungs. This is in contrast to a tree whose branches are erect and the leaves aerate the external

atmosphere. The respiratory system of the body is geared to aerate the internal atmosphere. Pranayama is commonly mistaken by medical professionals for hyperventilation. This is a situation when breathing is fast and forceful, with alterations in serum electrolyte levels and blood pH. On the contrary, in pranayama breathing is so orderly and slow and deep that such chemical changes do not occur at all. The system is rested. During hyperventilation, the system is strained. It is difficult to practise pranayama but easy to hyperventilate. The venous return is much better due to phasic changes in breathing. The pulmonary vascular bed relaxes to accommodate more inflow of oxygen and blood. Better diffusion of gases occurs, and elasticity is maintained to a ripe age. The haemoglobin/oxygen saturation is enhanced during kumbhaka (retention of breath) as there is enough time for saturation as the inspired breath is not let out. The inspiratory volume and the expiratory volume are made healthy. The vital capacity increases. Dead space is reduced as all parts of the respiratory tract are consciously used. The residual volume is decreased as more complete exhalation is performed. The cartilages of the entire respiratory tract with its inner lining of smooth muscle is exercised consciously. This prevents bronchospasm as control over autonomic functions are achieved. The alveoli are exercised in pranayama in contrast to other exercises where they are strained, as a massaging action occurs. This promotes excellent excretion of toxins and gases through the lung and a better intake of oxygen. Due to more efficient changes in blood gases, proper maintenance of blood pH is achieved. Due to better venous return, cardiac output is healthier. Lymphatic return is healthy, and excellent circulation of lung fluids is maintained. Better circulation of immune cells in the alveoli is promoted, increasing local immunity. All these maintain the microsystems of the body for a prolonged period. As breath is the key to life, practice of pranayama revitalises the respiratory system so that the energy levels of the practitioner increases. This is through energisation of the nervous system. The health of the nerves is linked to the breath. Microciliary clearance systems are stimulated, with proper drainage of secretions. The nasal part of the pharynx is flushed with healthy blood and local immunity is increased. Disorders of the upper respiratory tract like allergic rhinitis, vasomotor rhinitis, and chronic sinusitis are greatly relieved. This is due to the regulating action on the lining of the nasal passage, and the cells lining the tract never being over or under stimulated. Problems like polyp formation or increase in size of the cartilages in the nasal passage never occur with regular practice. The ventilation of the sinuses is made excellent, promoting good drainage. The healthy movement of the diaphragm massages the abdominal organs, improving their blood supply and peristaltic activity.

Digestive system The flow of breath in Sitali pranayama stimulates the taste buds. This sharpens the sensation of taste. The other types of pranayama in which the mouth is kept closed give rest to the salivary glands and their secretory functions as the mind is quietened. Hence, longevity of salivary glandular secretions is promoted.

The proper return of lymph and venous blood improves the digestive, absorptive and eliminating functions of the abdominal organs. Constipation is thus relieved. The stomach is massaged and this maintains healthy churning movements. Efficient breakdown of food particles is preserved. The intestines are contracted, and reflex expansion promotes excellent blood flow and venous return. Better absorption is promoted at the level of the intestinal lacteal cells. The gall bladder and liver are massaged, improving their cellular respiratory functions. Tissue longevity is promoted. Due to reduction in sympathetic tone, acid secretion diminishes, relieving stress-related peptic disorders. The massaging effect of the diaphragm on the kidneys ensures proper filtration at the glomerular level. Atherosclerotic changes are slowed down. This is due to the rhythmic contraction of blood vessels. The diaphragmatic muscle tone is enhanced, and the health of these sheets of muscles is protected. As the nerves are soothed by quietening of the senses in pranayama, digestive juices from different organs like the stomach, pancreas and intestine are maintained in an orderly manner.

The renal system The kidneys are massaged by the rhythmic movements of the diaphragm. This improves cellular functions. Renal lymphatic flow is stimulated, keeping the organ healthy. As the body is hibernated in pranayama, the excretory function is given rest. One can feel the bladder muscle tone alter by pranayamic practice as the bladder is partly under autonomic control.

The skin The skin is the largest organ in the body. Pranayamic practice promotes healthy excretory functions of the skin. It promotes excellent circulation in the dermis (as the nerves are kept very quiet, allowing a good state of blood flow) and provides nourishment. This leads to healthy cell production. The sweat and sebaceous gland activity is stimulated by pranayama. This does not mean that one will sweat more by pranayamic practice, but that toning up of glandular activity occurs maintaining healthy functions. Some types of pranayama can increase sweating — Bhastrika, for example. As healthy microcirculation is maintained, defense mechanisms of the skin are sustained. The skin does not become dry as in old age. As proper excretion of sebum is helped, practice of pranayama in the pubertal age group will help reduce the incidence of acne. The nervine functions of the skin are honed by pranayama. The touch and pain receptors in the skin remain razor sharp throughout life. Thermal regulatory functions of the skin are well regulated by pranayama. Skin tone is well maintained, helping cosmetic functions.

Endocrine system None of the important parameters like growth hormone, insulin, glucagon, cortisol, etc., change exponentially. In yoga, the bod y is exercised in a non-stressful manner. Therefore, one emerges feeling more refreshed than before. In the usual repertoire of exercises, the stress induced on the endocrine system is considerable. There are strong fluctuations in the levels of insulin because blood sugar levels reduce during dynamic exercise. This triggers the release of counterregulatory hormones like growth hormone and glucagon. In the long run, the body is subjected to a lot of wear and tear by

such a stimulation. The yogic system is peculiar in that the body is exercised without using the cellular reserves. Yet one cannot label it as an anaerobic exercise, as the intake of oxygen is enhanced though the usage is preserved. Thus, there is greater availability of energy substrate at the cellular level. The quietening of the nervous system energises the endocrine system which helps it function better, especially at times of stress.

Nervous system This is the area where the effects of pranayama can be felt wonderfully. The constant awareness of the mind on the breath and its rhythm quieten the entire body. The mind becomes tranquil. Neurophysiological activity is stabilised and the excitability of the sympathetic nervous system is reduced. Hence, relaxation ensues. Inhalation starts at the level of the pelvic diaphragm. The thoracic diaphragm and the accessory muscles of respiration are carefully kept relaxed. The facial muscles are also kept passive. Thus the organs of perception are pacified and lightened. One does not realise the tension on the organs of perception unless one has practised pranayama. As the cells on the face are relaxed, wear and tear is minimal; and the saying, "the face of the person practising pranayama is always youthful," can be understood from the scientific point of view. Pranayamic practice, therefore, stabilises the membrane potential of the nerves (the surface of every nerve has a resting electrical potential which is altered when electrical messages are transmitted) by reducing the overdrive. Thus the nervous system can function healthily for longer periods. Pranayama works particularly well on the various autonomic plexuses and the chakras. They could be either stimulated or energised, resulting in enormous energy. When the disconnection between the mind and body begins, pranayamic practice is spiritual in its effects. If asanas provide tranquillity for the inner organs, pranayama endows mental peace. Patanjali has said: "prayatna saithilya ananta samapattibhyam" (prayatna = continuing effort; saithilya = relaxity; ananta = infinite; samapattibhyam = completion): "perfection in an asana is achieved when the effort to perform it becomes effortless and the infinite being within it is reached." (Iyengar, op.cit., "Sadhana Pada", II.47.) From a practical standpoint, this means improved ability to withstand stress, reduction in stress as the mind is withdrawn, and a dispassionate attitude to everyday challenges. Insomnia is greatly relieved. But, this is so only if the personality type is within a "normal" range. All human beings face a certain level of stress in their daily life. If the response is inadequate, the result is depression and frustration. If the person is a perfectionist — overanxious, overexcitable — the result is overusage of the body and mind, exhaustion and nervous breakdown. As the nerves are soothed, better cerebral circulation is achieved. Pranayama is an aid to quieting the mind. It may sound paradoxical, but the mind has to be calm before pranayama is begun in order to experience the soothing effects totally. Nevertheless, the depressed or excitable person, when experiencing the fleeting feeling of tranquillity during pranayamic practice, is stimulated to search for the inner quietness which will help neurophysiological stability. To an extent, stability of the mind is first achieved by the control of the body through the practice of asanas. When the individual cell, sinew, tendon and muscle are all adjusted to ensure an optimum

level of stress, quietness envelops the body. When health of the body occurs the mind will be peaceful. Pranayama done on a regular basis alters the sensitivity of the nervous system, making it more energetic and vital. The sympathetic and parasympathetic systems are balanced, thus effecting neuroregulation of the circulatory and endocrine systems. Great energy flows, and the vital age of the body can be well maintained by the practice of pranayama. Pranayama should be done preferably before asanas are practised, early in the morning. The surroundings are very quiet and this helps one concentrate on the breath easily, to attend to the precision of practice of the ingoing and outgoing breath. Thus the effects of making the mind one pointed are enhanced. In the early morning, the nasal membranes are receptive and quiet. If a person has a problem of allergic sneezing on awakening, pranayama can be practised later in the day. If early mornings are not possible, it can be practised at any time, except bed time, provided the stomach is kept empty. Pranayama can be used for therapy. Problems of low and high blood pressure, allergic rhinitis, vasomotor rhinitis, sinusitis, recurrent infections of the upper respiratory tract, chronic headaches, migraine, peptic ulcers, anxiety states, can all be treated by the many kinds of pranayama, without the need for asanas. There are specific mechanisms by which pranayama works to give relief in such disorders. More claims are being laid praising yoga as a cure for many ailments. It is essential to realize that we must not mix cause and effect. The lay person cannot analyze the role of yoga. What kind of role has yoga in the following diseases? I have culled (from different sources) some common terms and conditions to briefly clarify: 1. Obesity — the cause of obesity has to be identified. Obesity is multi-factorial and hence one single therapy cannot suffice. Secondly yoga cannot burn calories like aerobic exercises or workouts in the gym and hence fat cells cannot be removed that easily. Those who feel they have shed pounds with yoga are incorrect in their analysis. It is possible that some physical activity can help in shedding a few pounds but an obese person cannot reach an ideal weight with yoga practice. 2. Nervous weakness — this is a vague term. One needs to be specific about the clinical condition before stating that yoga has a role to play. 3. Constipation — this is multifactorial in origin- diet, water intake, deficient nerve plexuses in the colonic wall etc. Yoga alone will not suffice. 4. Indigestion — this has plenty of reasons. The treatment depends on the causative factor. 5. Chronic cold & cough — concurrent sinus infections need to be ruled out. The surrounding atmosphere needs to be analyzed. Weak immune systems need dietary stabilization along with exercises. Anatomical abnormalities that predispose to coryza and cough need to be analyzed.

6. Flatulence — there are plenty of causes and treatment depends on the cause. The gut bacteria that are depleted by antibiotic therapy with resultant flatulence cannot be treated by yoga! Probiotics are needed. Hence careful thought is needed. 7. Urinary disorders — these need proper investigations and appropriate solutions. Yoga is a good adjunct and not a primary in this area. 8. Renal Calculi — this requires homeostatic manipulation of the diet and fluid intake. Yoga alone cannot help. More over passing a stone does not mean that asana practice has helped. Many stones pass out spontaneously. 9. Appendicitis — believe it or not! There is a website that proposes to treat this with yoga. This is ridiculous and one would lose the patient. We must refrain from such approaches. 10. Pyorrhoea — Yoga has no role here. Proper dental hygiene and dental care is all that’s needed. The list is endless. The patient should get proper guidance from the family physician before embarking on yoga as a therapy. This is of utmost importance. I have answered more questions in my second book — Yoga and Medical Science : FAQ.

Props It is time for us to understand the concept of using props in yoga. Props are gadgets that help the patient to execute asanas. They have revolutionised the concept of practising yoga. In ancient days yogis hung from trees with the help of ropes in sirsasana. This was a natural prop. The first prop was used by Sri B K S Iyengar in 1965 when he found that he could not execute Baddha Konasana. To help the muscles stretch, he placed two heavy stones on the thigh muscles. He also found that patients needed help to sustain postures and he physically supported them, whenever needed, at the various parts of the body. This led to the creation of props which are quite sophisticated today. A beginner’s body may be very stiff. Secondly, medical problems will not permit patients to practise asanas in the normal way. Thirdly, the practitioner may be aged. Fourthly, the prop helps the person to execute the pose correctly and to understand the mechanics of the pose easily. In such situations, props are very useful. Props help the practitioner do a pose that may normally not be possible. Props do not tire or take the body beyond its capacity. They give rest to the body, allowing the pose to be done for a maximum period of time with minimum strain. Pulse rate and blood pressure do not rise. Refreshment and rejuvenation come instantly to the practitioner.

Trikonasana with belt, brick and horse.

Props are silent guides if there is no teacher. The body is exactly grafted on to the prop so that there is no exertion. For example, learners or patients who are unable to do inverted poses can use the ropes suspended from the ceiling. Props can be classified: (i) wooden brick and foot rest; (ii) belt; (iii) ropes; (iv) slanting plank; (v) chair, stool, bench and box; (vi) the heart rack, ladder stool and drum; (vii) bolster and pillow; (viii) bandage; (ix) weight; (x) the horse, big and small.

Wooden brick and foot rest Wooden bricks are commonly used in standing poses as supports for the knee, heel and hip joints. For example, when Trikonasana cannot be done to the full extent due to spinal stiffness, the hand can be rested on a brick to learn to get the spinal lengthening (illustration, previous page). To realign the tail bone, a brick is positioned in Setu Bandha Sarvangasana. Six bricks can be used in the same asana for providing a lengthening effect to the spine. This is useful for cardiac and asthmatic patients. Bricks can be used in inversions, between the thighs, to provide stability to the pose and learn alignment. In back bends, bricks can be used to support the hands and elbows. Bricks can be used in forward bends to correct any pelvic tilt that might occur in stiff individuals. The foot rest deserves special mention (illustration at right). It is a curved prop designed to support the arches of the foot and stretch the calf muscle a great deal. It relieves osteoarthritic knee pain, ligament pain in the knee, ankle and foot. Within a few days of practice it abolishes, permanently, nocturnal cramps from which millions of women suffer. It enhances blood circulation in the popliteal artery (the artery that supplies blood to the calf muscle) and cures ischemic muscle pain. Neurogenic

calf muscle pain of certain etiologies can also be cured. Patients suffering from thrombosis and inflammation of the veins of the calf muscle find great relief in practising Tadasana on the foot rest. It is very valuable for preventing calf muscle fatigue from prolonged standing. It is highly useful for athletes to improve the quality of their calf muscle stretch.

Belts Belts are found useful in all standing poses. They help stabilise the functions of the muscles and joints. Ligament strains are relieved. In Virasana, for example, the crushing of the cruciate ligaments can be removed. In Trikonasana, lengthening of the spinal column is achieved by the belt and stability is acquired in the hip joints. The head of the femur is manipulated into the socket (acetabulum). The proper curve of the spinal column thus achieved gives elasticity to the diaphragm. In Sarvangasana, the use of the belt round the shoulder elongates the torso and realigns the shoulder muscles. The heart and lungs are made to expand better in the pose and the kidneys are flushed better. In Supta Baddha Konasana, the belt is essential for the proper lift of the uterus. Menstrual pain in the abdomen is relieved. Prolapse of the uterus is prevented. It is useful in Baddha Konasana, to heal bursitis of the hip joint.

Tadasana on a footrest.

The use of belts on the legs in Sirsasana ensures proper alignment of the spinal column and hips. The belts are used in treating arthritis of the shoulder and knee by bracing the arms behind the back or help the patient perform a proper Dandasana by holding the legs together. The entire joint architecture is opened. In back bends, the use of belts on the thighs lifts the organs upward and prolapse is prevented. Spinal extension is also better. For patients who get pain in the sacroiliac joints during back bends, the use of belts is a must as instant relief is got by soothing the ligaments.

Ropes Ropes have plenty of uses. Ceiling ropes are used for practising head stand in a special way by hanging upside down (illustration above). This can be done either in Baddha Konasana or with the legs straight. As the normal practice of head stand is unadvisable for patients with high blood

pressure and other disorders (only in the beginning, till the disease is controlled) this method, which can be followed without causing a rise in blood pressure, is safe. Asthmatics and patients with migraine should practise the same method. Even cardiac patients can use the ropes without any danger. Pulse rate and blood pressure do not rise. Ropes from the ceiling are a boon for patients with sinusitis, as the inversion creates a lightness in the sinus at once. Medically, it is a wrong concept that patients with sinusitis or high blood pressure should avoid head stand. In fact, it is most beneficial if done after Shoulder stand and Halasana have primed the body initially, draining the secretions. In the case of high blood pressure, practising head stand on the ropes does not increase blood pressure, provided the body has been primed with other poses earlier.

Head stand on the ropes.

Backbend on the double ropes.

Wall ropes are used for spinal problems like prolapsed disc and bamboo spine, as well as in hypertension, migraine and asthma. In the case of bamboo spine, the ropes help the patient get back the elasticity of the spine (illustration above). Patients with prolapsed disc can do head stand in this way also. This is called ‘Traction Head Stand’ where pelvic traction is used. In Adho Mukha Svanasana, the rope round the hips helps in elongating the abdomen, spinal column and shoulder joints. The practice of Dog pose for migraine sufferers and hypertensives is helped by the wall ropes.

Slanting planks Slanting planks are most commonly used for patients with weak, fractured or injured wrists who

cannot do a hand stand against the wall (illustration at right). It is also used in the standing poses for patients with tight calf muscles, particularly in Adho Mukha Svanasana. These planks are used in menstrual problems where low back pain occurs. They are used in forward bends under the thighs to help the uterine musculature to relax. They can be used in forward bends to correct asymmetrical pelvic tilt. The role of slanting planks in cardiac cases is to give an extra stretch to the dorsal spinal muscles, especially for patients who have a caved-in chest, so that the thoracic cage opens better and the blood flow to the heart increases. When angina occurs at rest, relief is obtained if Supta Virasana is done with the slanting plank. For certain knee problems, if quadriceps muscle contraction is weak, the slanting plank can be placed under the sole to help the contraction and stretch the calf muscle properly. For patients with arthritis of the shoulders, Pincha Mayurasana done with elbows on a slanting plank helps in aligning the deltoid muscle and stretching the muscles of the armpit. For arthritis of the shoulders and wrists, the slanting plank kept at the back of the body helps get the movement of the shoulders realigned.

Shoulder stand with chair and bandage.

Hand stand on the slanting plank.

Chair The most frequent prop in use, this is usually a folding chair (illustration at left) or a straight-backed armless chair. It is used for twisting poses like Bharadvajasana (for spinal problems), Sarvangasana, half Halasana, back bends like Viparita Dandasana, etc. All patients need this simple prop to practise their asanas. For the elderly age group, cardiac patients, asthmatics, hypertensives, patients with cervical spondylitis, shoulder disorders, patients with menstrual disorders, spinal problems where the spine needs to be stretched open — these are some of the situations where the chair helps the patient execute the pose without strain. It also gives confidence to patients who may harbour doubts about their capacity to perform some of the asanas. The chair is most useful for cardiac patients to perform Viparita Dandasana which helps avoid a bypass surgery.

Half Halasana on the stool.

Stool, bench and box The stool is commonly used for practising the seated or standing twisting poses against the wall, as in Bharadwajasana and Marichyasana. It is very useful for half Halasana for which it finds the most common use (illustration above) helping ailments like low and high blood pressure exhaustion, headaches and sinus problems. It can be used for practising backbends also. Its use can be substituted by any stool available at home provided the height is adjusted for the individual using it by adding a pillow on top of it if needed. The bench and box is very useful for practising Setu Bandha Sarvangasana (illustration below) for patients with coronary diseases, high blood pressure, lung ailments like asthma and emphysema, etc. As the normal method of performing the pose is medically contraindicated for them, the prop helps them achieve the same without strain and with quicker benefits.

Setu Bandha Sarvangasana with the bench and box.

Heart rack, ladder stool and drum The curved rack represents one of the marvels of the concept of props. It can be dismantled and carried to any place in a bag. It represents a very advanced back bend known as Viparita Dandasana (illustration on following page). As beginners and patients cannot do the pose which is too strenuous, the prop helps. It is particularly useful for cardiac disorders, asthma, emphysema, gastritis, prolapsed uterus and bronchitis. By using the prop, fatigue is relieved promptly. Sacroiliac pain is relieved by practising back bends on the rack, particularly Bhujangasana and Salabasana. This reduces strain on the lower back. It is useful to remove fatigue during menstruation. It finds a place in the treatment of inguinal hernia. Cramps of the uterine muscle are removed. Peptic ulcer disorders and gastric distension due to wind are relieved. Insomnia is greatly reduced by the rack as the blood flow to the brain is increased and the nerves in the medulla oblongata are rested. It is useful to invalid patients as a substitute for Head stand. The drum (illustration next page) is another useful prop to practice backbends for patients who are unable to adjust their bodies to the rack. The concave contour of the spine fits perfectly into the convex contour of the drum, massaging the internal organs.

Viparita Dandasana on the heart rack.

The barrel drum.

Urdhva Dhanurasana with the ladder stool.

The ladder stool is highly useful for beginners or patients with cardiorespiratory ailments to learn and master Urdhva Dhanurasana (illustration below left) without strain. The benefits are very quick and the relief felt by the patient is something to be experienced, particularly for those suffering from angina. The shoulders are stretched to the maximum and relieve arthritic pain. Patients with cervical spondylosis are benefitted. The aged can learn these difficult asanas without difficulty.

Bolsters and pillows The most common use of bolsters or pillows is for Supta Virasana (illustration on following page), Sarvangasana on the chair and Viparita Karani against the wall. The latter has to be done with support, particularly by cardiac patients. Cardiovascular performance improves. In half Halasana, a bolster is used as a support for the spine and diaphragm. This helps in proper relaxation of the diaphragm. Exhaustion and headaches are relieved. For patients with very stiff spinal muscles, who need to do Supta Virasana, one or two bolsters placed under the spine give relief from asthma, angina, exhaustion and other conditions. The actual pose is to be done on the floor and, as this will strain the spine, bolsters are used. They thus help support the heart and lungs. When Supta Virasana is performed immediately after a heavy meal, relief is obtained from fullness in the stomach.

Supta Virasana on the bloster with weight.

Bolsters and pillows are used for Setu Bandha Sarvangasana to get the appropriate curve and for forward bends to rest the head in the case of patients suffering from headaches. Special types of bolsters are used for patients with asthma, high blood pressure, and anxiety neurosis to lie on and do pranayama. The support given by bolsters helps them to relax the pelvic diaphragm, and easy breathing occurs, reducing blood pressure.

Elasto-crepe bandage This is used in both asana and pranayama practice. In asana practice, it prevents rise in tension of the facial nerves and arteries in the neck and face. In pranayama, it is used to cut off the senses from contact with the external world and induce deep relaxation. As the auditory and visual stimulus is cut off the nervous system relaxes faster. This is very useful for therapy. The practice of certain asanas with the bandage covering the eyes and ears relieves headaches. There is a soothing effect on the nervous system and particularly the eyes. When patients with high blood pressure or migraine do yoga, it is essential that the crepe bandage be used; otherwise, the blood pressure does not reduce in the former and relaxation does not occur in the latter. Its role is very important in the performance of head stand by patients with anxiety states. In the practice of forward bends, the use of the bandage rests the senses and relieves chronic headaches. The use of the bandage is a preventive for persons who are prone to developing pressure in the eye for certain preexisting anatomical reasons.

Weights The weights available are in various sizes: 25 lbs, 50 lbs, 100 lbs, etc. The smallest of these is used in Savasana to relieve nervous tension. Gradually, the patients learn to relax by themselves. For patients with high blood pressure, the placement of weights on the forehead eases the frontal brain

and deep relaxation occurs. Savasana done with a weight (25 lbs) on the forehead gives immediate relief to headaches. The large weights are used for joint problems. In certain types of chronic backache, the weights are placed on the sacroiliac region. Patients who get tremors in the thighs in Halasana need weights. It is useful in Hasta Padangusthasana for creating space inside the hip joint by hanging the weight with a rope on the joint. This relieves pain in the hips due to arthritis, bursitis, etc. The weight can be used when Supta Virasana is practised, to help flatten the lumbar spine to the floor. It also helps to stretch tight groin muscles in the same pose by pushing the groin to the floor.

Cardiac bench The cardiac bench is very useful for cardio-respiratory disorders. In the case of a respiratory ailment like emphysema, as the patient lies down on it, relief from dyspnoea occurs. It helps in the learning of pranayama by cardiac patients and asthmatics. It can be used to perform Setu Bandha Sarvangasana by cardiac and asthmatic patients. This bench helps patients with cervical spondylosis and cardiac ailments who cannot do Setu Bandha, as the actual pose might place a strain on the neck muscles which a healthy person can withstand. The pumping of the heart muscle is made stronger; this can be achieved easily with the prop.

Stump The stump is used for people with cervical spondylosis to elasticise and open out the neck and the dorsal spine. It can also be used to perform back bends or for tail bone problems.

Horse This is similar to a gymnastic horse and is most useful for spinal disorders like slipped disc, low back pain, arthritis of the knee and hip and cardiac problems. Many standing poses can be performed with the horse. Trikonasana and its variations, Parsvakonasana and its variations and many forward and back bends can be performed with the help of the horse (illustration at left). The gadget is dismantlable.

Trikonasana with the horse and the heel pushed into the footrest.

Setu Bandha Sarvangasana with the little horse.

Urdhva Dhanurasana and Kapotasana can be practised on this by healthy persons. Patients can use it too, as it helps relieve cardiac ailments by expanding the thoracic cage. If one does not possess this prop, the asanas can be done using windows on the wall or a long grill to gain similar support. The corners of a doorway can give alignment for standing poses. A bannister, if running horizontally, can serve the same purpose.

The small horse is yet another marvel which helps perform Setu Bandha Sarvangasana perfectly and in an intense manner, an aid which no other prop provides. This is very useful for cardiac patients and healthy beginners. The chest expands fully, improving cardio-respiratory parameters. The cardiac muscle is made strong and the coronary blood flow benefitted. The arch of the aorta is made elastic. This is also possible by performing back bends with the other props. The kidneys are squeezed. The abdominal organs are stretched and their blood supply increased. The little horse is very useful in helping a patient with a triple vessel block avoid by pass surgery. Angina vanishes rapidly with its practice. The patient using the gadget recuperates very fast and this enhances self confidence. It prevents the patient from committing mistakes in the execution of the poses. This gadget is also useful to help practice forward bends by beginners and patients. It is hence useful for teaching the proper spinal stretch in forward bends. Patients with chronic headaches secure good relief by practising forward bends with the head resting on the prop.

Some questions about props Two common questions that are often put to me are whether the use of props is really yoga and, if a patient is not able to do a pose, whether the prop pushes the body beyond its limits. The answer to the first question is that it is definitely yoga: an intelligent use of the asanas to suit the patient. If a patient cannot perform the actual pose, methods of achieving it have to be worked out to provide benefits, yet without aggravating the clinical condition. For the patient props are meant to rest the body. They are all passive poses, more passive than the actual pose. Secondly, no prop can push the body beyond its capacity. Props are meant to support the necessary areas of the body which are not firm or stiff. In fact, even if the patient is very old, he or she can use props and get the required benefit. Just as a patient with a fracture has to wear a cast and mobilisation has to begin as early as possible, the patient practising asanas has to be helped in their execution. For example, a 70 year-old patient with a cardiac problem can comfortably use the heart rack without strain. Medically, the concept of using props is a sound technical proposition. Since the props cause no strain, there are no side effects. In contrast to this are the conventional yogic schools where no props are used. Clinically, the benefits are marginal. The practice of Head stand, for example, is not recommended to people with spondylosis of the neck. But with the aid of ropes hung from the ceiling, the pose can be done without detrimental effects to the neck. In conventional yoga, asthmatics are not given any props. This is very irrational as their lungs need support. Also, such patients are taught pranayama. When they are breathless most of the time how can pranayama be done? The respiratory rate has to be normalised first. When even a normal breath is difficult, how can a maximum inhalation be done? In conventional yoga, for the management of spinal disorders like slipped discs, etc., standing poses are omitted. It is impossible to get total relief without them. Realignment of the sciatic nerve cannot be done without standing poses nor can the contracted spinal muscles be lengthened.

The final question that one must consider is the cost of investing in props. Bolsters, blocks, belts, pillows, chairs and bandages do not cost much. Props once bought last for a lifetime. They are very durable. There is no maintenance cost. It would be a sound investment as the expense of buying drugs does not exist. Moreover, on a long term basis, medication and surgery can definitely be avoided. Health care is made most cost effective. Innovations can be made, if one does not have the exact prop. Standing twisting poses can be done near a wall using a chair. The use of the rack can be supplemented by a stool or a folding steel chair or a sofa. One can find innumerable props around one’s house. For example, the bed can serve as a prop to do Setu Bandha Sarvangasana. The little horse can be substituted by a small foot stool placed over the leg while bending forward. Some patients may have to use props all the time; others may be weaned off them. For example, cardiac patients should do the poses on props for a certain time frame after which, when the clinical condition is better, they must practise the way normal persons do. In the case of asthma, props can be discontinued after a few years of practice. Sufferers from migraine can be weaned from props earlier.

SECTION IV MEDICAL DISORDERS AND THEIR MANAGEMENT Yoga is a primary form of medicine. Integrating it with Western medicine enhances health care. Discussed in this section are several common and important medical disorders, the concepts and side effects of western medical management of these disorders, the use and wide scope of yoga in mainstream medicine, its rational application as a primary modality of therapy or as an adjunct to western medicine rather than as a mere stress relieving system, and its long term benefits. This section offers the rationale in helping us understand the value of yoga as a system of both prevention and cure, the depth of which was realized by our ancient seers without medical research facilities.

Yoga as Medicine Therapeutic yoga is the clinical application of the science of hatha yoga for various medical disorders. The pioneer of therapeutic yoga is Yogacharya B K S Iyengar of the Ramamani Iyengar Memorial Yoga Institute, Pune, who has more than 70 years of experience in this field. His adaptation of yogic asanas to treat individual medical problems led to the creation of props. Aged persons, injured persons with spinal problems, amputees, all could make use of the props and gain the benefit of yoga. Thus, the use of yoga was made available to all patients, regardless of their medical problems and their bodily condition. This is where conventional yoga schools have found it difficult when it comes to dealing with serious clinical problems like heart failure and stroke. Such patients are medically not permitted to do yoga the regular way because they are too incapacitated and their clinical condition might be aggravated. Today, where all other yoga schools have failed to treat a patient, Sri B K S Iyengar has succeeded because of his scientific approach to the problem. I can vouch for this personally. By attempting to practice yoga from books and by wrong practice of certain poses, I had injured some ligaments and muscles in my body. The actual strain was at the lower back and the ligamentum teres in my left hip joint. This is a ligament deep inside the socket of the hip joint. Conventional orthopaedic management failed to help. Conventional yogic approach also failed. On the very first day of yogic treatment by Sri Iyengar, the placement of a weight on the thigh muscle when a certain pose was done stopped the pain. In one month, the ligament had healed. Yoga is a practical subject and has to be learnt as such, not from books. It is a living science and not a dead subject. It deals with movement and posture and does not theorise about them as modern anatomy texts do. The uniqueness of "Iyengar yoga" The system of yoga taught by Sri BKS Iyengar has popularly come to be known as "Iyengar yoga". There is a distinct difference between this and other systems, which places his teachings far above all else. This is particularly so when one analyses his methods medically. Medically, when the human body is used in exercise and the internal organs are used along with the external, certain principles have to be followed in order not to injure the body. In most yoga schools, there is no depth to the teaching of yoga, as can be seen if one happens to be a physician. Secondly, this system can be used in mainstream medicine to solve major medical problems where other systems have failed. I have

studied different systems and have found that there is a lack of anatomical guidelines in the execution of asanas and pranayama. To illustrate this I will give several examples. In standing poses (Trikonasana, for example), if one observes students trained in other systems, there is no arithmetical and geometrical perfection and certain areas are ill affected. Again, in headstand, there is no guideline in other systems on how to prevent pressure on the brain due to the increase in blood flow; whereas, in "Iyengar yoga", one learns to adjust the blood flow in such a way as to obtain the correct effect inside. This can be confirmed by sonographic studies. The frontal and the back brain have to be kept parallel in order to ensure proper and optimum blood flow and relaxation of the neurons of the brain. Unless one does the different systems, it is difficult to understand this. Generally, yoga is done slowly and with a lot of stretching, but there is no strength in the stretch and contraction is totally forgotten. Moreover, I have seen any number of patients coming to me with no relief from other systems and when the protocols are followed relief results very soon. Any exercise has to strengthen, tone up the system and preserve the body as one grows older. To achieve this, the different parameters of the body need to be observed to find out if they are used to the optimum. As a medical professional, I find that only "Iyengar yoga" achieves this. In this system, the body is made robust both outside and inside. A good example is the practice of backbends which provide vitality to the system. In "Iyengar yoga" one insists on a certain geometric shape of the asana, which alone provides cardio-respiratory health; whereas, in other systems, one can observe incorrect shapes and practitioners suffering ill health later on. For example, in Urdhva Dhanurasana, medically, only at a particular angle of the dorsal spine does the heart pump efficiently. This is logical as certain angles compress the heart. The correct angle is taught in the Iyengar system. The skin on the front and back of the body have to be kept parallel to each other as far as possible. The pelvic girdle should not collapse which then results in compression of the pelvic organs. Whether the geometry of asanas is at all necessary is a concept that is not thought of in other schools of yoga. Subtleties of yogic practice are available only in the Iyengar system. The test comes when the practitioner suffers pain or disease, or secures no relief, in spite of practicing yoga, and relief results from the moment the correct method is learnt. I had severe backaches even though I practised yoga and no school of thought gave me relief. For years I suffered. Stretching the spine in a different way, as taught by Sri Iyengar, immediately provided an immense change. This made me realize that there is much more to yoga than generally understood and my interest was provoked. This cannot be appreciated by lay persons who do not know anatomy. In "Iyengar yoga", instructions are given on how to strengthen tendons, arteries, veins, bones, organs, etc. An obvious example is Sri Iyengar himself. Today, there is no one of his age who can still perform the asanas he did as a child of 14 and one can easily appreciate the vitality in his body the moment he demonstrates the asanas. I am sure any medical professional who has observed his demonstration can vouch for this. In "Iyengar yoga", the mind is brought to focus on different areas of the body for correct adjustment. In other systems, breathing is taught instead and this is medically harmful. In the practice of asanas, until the lungs can expand perfectly, only normal breathing should be observed. This is a vital medical tenet. It is also mentioned in the Yoga Sutras that, unless mastery in an asana is reached, breathing

should not be done. This is ignored by all other schools of yoga. In a beginner, the breath is shaky and when asanas are practised with shaky breathing ill health results. In "Iyengar yoga", breathing in an asana is taken from the superficial to the subterranean plane to ventilate the cells of the body and this is achieved only if the relevant areas can open up to the breath. This means proper performance of asanas. In the Hatha Yoga Pradipika, it is said that the mind is the king of the senses and breath is the king of the mind; calm the breath and the mind is quiet. This should be carefully followed. When one medically examines persons trained in other schools, their body parameters lag far behind students trained in the Iyengar system. The body has to be kept dynamic and yet relaxed. In the Iyengar system, the performance of asanas creates a certain space between the spindles of the nerves and skin, resulting in profound neurological relaxation. This happens only if every part of the body is put to use. I have already spoken about the standing and inverted poses. Coming to the forward bends, if the diaphragm is not kept parallel to the floor, the heart is compressed. If the anterio-posterior diameter is altered the thoracic organs are pressurized. This is taught only in the Iyengar system. In twisting, the inner and outer spine have to be kept in alignment, else the spine is not used symmetrically. The chest shape should not vary from Tadasana at all. In balancing poses, the mind should be kept calm, which means the front and back portions of the body have to be kept like the scales of a balance and one should distribute the body weight in such a way that the pose is arithmetically balanced. In symmetrical and asymmetrical poses like Bakasana and Eka Pada Bakasana, one has to really find the centre of gravity for the mind to be relaxed. Balancing poses therefore mean a balanced action of the body and mind in an asana and not a pose full of tension. Similarly, there are many features of each pose which have to be followed for perfect safety in practice. Then, as Patanjali says, stira sukham asanam ("the posture is pleasant, comfortable and easy"). The aim of yoga is sammatwam yoga uchathe — yoga should bring to the body and mind an even functioning of the physical, mental, emotional and psychological parts of our being. The asanas and pranayama should be practised to provide a perfect balance between the cells of the body. This is integrated yogic practice. If integration is achieved, many medical problems can be easily prevented or treated using yoga. But there are so many systems of yoga which are in vogue today each claiming to be more effective than the other. There should be only one base to judge the progress of the patient i.e. the clinical parameters. Yogic "Surgery" "Surgery" in yoga? Is it not strange? Yes, there are radical methods in yoga too for curing diseases. These are known as cleansing techniques. But these are almost never needed as asanas and pranayama do their job most of the time. These "surgical techniques" consist of many methods, which have a propensity of curing certain ailments. For e.g.: a thread or nasal catheter introduced into the nasal passage (called sutra neti) and brought out through the mouth is beneficial for relieving chronic nasal problems like sneezing, sinusitis, blocked nose etc. Using boiled cooled water (jala neti) or milk in the nostrils is yet another technique. The liquid passes into one nasal passage and comes out

through the other. This is said to be beneficial for many nasal disorders. Again, a clean cloth several feet long passed into the esophagus (dhauti) and into the stomach and drawn and withdrawn several times is beneficial for acid peptic disorders and digestion. Swallowing several glasses of saline water and regurgitating it, is said to purify the digestive system. Vomiting saline water can cause electrolyte imbalance! Passing an enema tube (the yogis used soft firm objects like a stump of a banana plant) helps relieve disorders of the lower gastrointestinal tract. These can be supervised but they are not needed. There are many such concepts but these are not to be done by the average practitioner as they are invasive in nature and fraught with inherent hazards. When performing neti, the water can leak into the sinus, stagnate, and one can end up with chronic sinusitis. Safety of the patient is very important. Many yogic schools teach these methods to people without realizing the medical implications of doing so. The person who may be an expert in doing it can never understand the importance of anatomy and its dangers. Neither does the yoga teacher understand the depths of the problem. Hence these methods are better avoided. Even the yogic texts say that these are to be used only if asanas and pranayama fail – and this rarely happens. For eg: Sarvangasana and Halasana work par excellence for sinus problems. It is important to understand that asanas and pranayama cleanse the cells of many toxins and free radicals as highlighted in the book. As the cells themselves are cleansed, the cellular responses automatically change. This arrests, or cures the underlying disease condition. By passing the cloth into the stomach the surface of the cells are cleansed, but certain asanas like Viparita Dandasana, Supta Virasana work on the vagus nerve itself and reduce the acid secretion. Obviously this is superior to the other methods as the very reaction of the body is corrected. Consider the sutra netidue to the friction of the thread on the delicate nasal lining, the sense of smell could in certain cases be affected. Pranayama changes the responsiveness of the sympathetic and parasympathetic nervous systems and relieves the condition. Pranayama cleanses the sinuses par excellence. I had a patient with very severe nasal allergy and she could not practice pranayama as the nose was perpetually blocked. All medical measures proved futile. Pranayama done persistently relieved her completely. As a medical professional I was very skeptical as hers was a very bad case — yet pranayama made her normal! The best manner of managing a disease is with non invasive methods. That which heals with the minimum contact with the body and is the most beneficial of all healing methods, hence asanas and pranayama are considered the best. Today this is very popular in medicine. One must clearly realize that our body has its own cleansing process, which must not be interfered with. It will function very well if we are moderate in diet, exercise and leave the rest to nature. The body has its own intelligence. For example; the intestinal goblet cells secrete mucus every day, which lubricates the lining for absorption of food. . These cells are shed and replaced every day. Millions of our cells are denuded and replaced daily, continuously. All that is needed is to provide fresh blood to the cells and remove toxins that accumulate. Add to this a calm mind and you have healthy digestion.

The mind in yoga To maintain bodily health, the mind is given great importance in yoga. This is not so in modern medicine which is one main reason for its limitations in many situations. We medical professionals do realize that stress can aggravate diabetes, ulcers etc yet we are at a loss to solve this situation with our conventional training. Yoga alone can fill this lacuna in our approach. As highlighted before, the yamas and niyamas if followed provide for stress relief helping towards right living. These are ignored by adults as moral values meant for kindergarten levels. Yet it is the adult human being which has messed and spoilt the world at large today, not the child. There is violence in every facet of our life- a lawyer is violent when he defends a criminal case; a doctor is violent when he exploits a patient for money; a business man is violent when he indulges in professional corruption, a builder is violent when he sacrifices the environment to achieve his ends etc. Many examples can be given but we never like to accept our traits. This leads to ego, which perpetuates wrong action and endless misery in life. Such wrong action builds stress in our mind and with this comes a host of negative energies, which damage our delicate mind and body- fear, anger, hatred, uncertainty, etc. This causes release of stress related chemicals which in turn cause high blood pressure, breakdown of the immune system, insomnia etc. Not being able to sleep well is a common ailment which can cause many disorders. Stress related dreams damage the cardiovascular and nervous system. The person succumbs to a sleeping pill, which is nowadays viewed as something not abnormal by even physicians. If the mind is happy, contented and restful, sleep will refresh the body. How can a tablet provide this? It cannot work on the mind, which is more powerful than any drug. Therefore yoga lays emphasis on a ceiling for our desires. This prevents stress. It does not mean that one has to be an ascetic. There is no magic method to remove stress. It is our attitude that matters. How does one have that attitude which prevents or reduces stress accumulation? The only way is to read yogic philosophy from different sources and put into practice at least a few such concepts. Longevity is enhanced due to a happy mind. This is also endorsed by modern medicine. To prove that happiness helps towards a better quality of life, many are the parameters used for such studies in medicine- listening to music, games played habitually, trekking, sexual habits, better interpersonal relationships etc. Ultimately it is all in the mind- one can be calm even if the Empire State building crashes or even if one gets the noble prize. The person who exercises regularly also should have a calm mind. Exercise should calm the body and mind and not tire it. Nowadays even when we exercise we listen to loud music. We may claim that it relaxes us but clinically, we are never as calm when we exercise to loud music as when we exercise in quietude. Not realizing the need for the same, many feel bored to exercise in quietness. Keeping the mind calm when one exercises, a healthy chemical surge occurs which prolongs the life of our body cells. Different exercises done today have different strains on the mind and hence on the body. For e.g.: in

weightlifting there is a terrific strain on the senses and this in the long run keeps the cells of the brain and the mind in a certain quality of "hardness". The same cannot be said for the musician where the mind is kept soft and resilient. In swimming for instance, the mind is made to adjust to a new media (water) and one is made to react constantly to a different surrounding. To reiterate, if one listens to music during exercise as in aerobics, the mind never get the rest. As we are mentally active throughout the day it is highly important that the mind is rested for a period of time every day. One of the best times is during exercise as beneficial chemical changes occur at this time. This coupled with the mental attitude of quietness strengthens the body and mind par excellence. But we are unaware of all the subtleties of our physiology. The problems faced by an individual during a lifetime and the attitude towards it determine health of the body and mind and longevity. The more we are resilient, the healthier we are. The more we are weary of life (and this happens all too early- by the early middle age) the greater the chances of suffering ill health. Hence the ancients have given us clear guidelines for mental health and physical. They never separated the two. When asanas are practiced, apart from silence in the mind, which is necessary to observe precision of practice, our psyche is taken into different geometric shapes as the body moves. This benefit is special to yoga. Resilience of our mind is thus made a part of our daily living. This is particularly so when pranayama is done. The mind and our very consciousness are kept deep inside as breathing begins, to allow the breath to expand linearly, horizontally, circumferentially and upward. This needs a total quietness of the entire being. It is impossible increase the duration of inhalation or exhalation by muscular force. As inhalation begins the mind tends to go outward at once and this tendency is countered by consciously directing the senses deep within. This allows the duration of inhalation and exhalation to increase. Such training methods are unknown in other systems of exercise. Below I have highlighted some of the important attitudinal guidelines from the Yoga Vasishta needed for mental and physical health. There are several of them, which if deeply studied, enlighten us about the attitudes of our ancient sages, which helped them lead a peaceful existence. 1) This has been obtained by me today. I shall obtain this beautiful thing- thus I have no thought or anxiety. Thus I live long without disease (Samvid op.cit; 737). 2) What has happened to me today and what will happen early on the morrow again? There is no fever or anxiety of this nature. Therefore I live without disease (Samvid op.cit;739) 3) I do not fear the pains of old age and death; nor do I rejoice the pleasures of obtaining a kingdom. Therefore I live without disease (Samvid op.cit; 740). 4) I view (or discern) straightforwardly everywhere with a (mental) power which is not fickle and with a beautiful look which is affectionate and innocent. Therefore I live without disease (Samvid op.cit; 743). 5) Having renounced (mentally) that which I do or eat, even though possessed of that, my mind resorts to abstraction from (the doership or enjoyership of) actions. There for I live without disease (Samvid op.cit;744) 6) I am delighted on obtaining the agreeable and unhappy when a person is afflicted. I am also the

beloved friend of all. Therefore I live without disease (Samvid op.cit;746) 7) I view everything that is worn out, broken, loosened, powerless, disturbed, crushed or gone to destruction as new (or fresh). Therefore I live without disease (Samvid op.cit;746) I am sure that if we uptake even one of these, we can live without mental and physical ailments or it will at least give us the strength to face situations. To sum up, when we are faced with a health problem much of the solving of it depends on our mental attitude. Western medicine is a highly advanced and sophisticated science, very useful for a variety of acute and chronic diseases. But at times the role of allopathy in treating chronic diseases is limited by the fact that side effects of drugs are ill tolerated and the root of the problem is not tackled. The drugs, being artificial chemicals, are bound to harm the system in the long run. A drug does not change the personality of a person. It merely removes illness. Yoga, apart from eradicating an illness, changes the person’s perspectives of health and disease. Homeopathy is very, very useful for many diseases. But again, in some instances, in the long run, the root of the problem may not be taken care of. Many other forms of therapy for various disorders are only temporary. These methods are of use in certain conditions but in the long run are not effective or needed. For example, in a disease like arthritis where the alignment of the bones has to be changed, homeopathy, magnetotherapy, acupuncture, physiotherapy all relieve only the pain and inflammation and that too only marginally. Yoga provides excellent relief and, at the same time, realigns the skeletal structure which is the root of the problem in an arthritic joint. Thus, the solution is permanent. The aim of therapy is to cure disease and relieve pain. Yoga corrects the internal malfunction. All other systems relieve only symptoms, which is part of the ultimate aim. I shall explain this with the example of high blood pressure and the use of magnets. The pressure which is refractory to allopathic treatment may respond to the use of magnets, but therapy cannot be halted after the pressure is normalized. Yoga corrects the disorder and prevents the body from malfunctioning again. It is impractical to consume a drug or apply magnets every day. Yoga practised daily is more logical. In a disease like migraine, other systems alleviate the pain but yoga regularises the blood flow to the brain which lacked perfusion during the attack and restores the stability of the nervous system. Hence, the relief is more tangible and the method of cure more sensible. Many more examples can be given. What I would wish to emphasise is that, in order that health be maintained, yoga is the rational answer. It is not only a curative science, but is also a preventive science. The scope of therapeutic yoga is quite wide and an array of disorders, including ischaemic heart disease, cardiomyopathy, arthritis, sinusitis, allergic rhinitis, bronchitis, asthma, diabetes, hypothyroidism, osteoarthritis, rheumatoid arthritis, SLE, spondylosis, migraine, cluster headache, can be treated. Infections, malignant tumors, congenital and genetic disorders cannot be treated by yoga. They require other appropriate therapy. The allopathic management of disorders like migraine,

arthritis, ischaemic heart disease, etc., is useful but, in the long run, to switch to a natural system like yoga is more sensible. The lesser the body is drugged or interfered with by invasive methods, the healthier it remains. The yogic management of all these disorders has no side effects. The relief is also quick. Thus it is important to have an intelligent combination of allopathic medicine and therapeutic yoga to treat diseases. In the next few chapters I have dealt with some common disorders and discussed the modalities of treatment. It would then be easy for us to understand the exact role of yoga and Western medicine in health care.

Cardiovascular Disorders These disorders form one of the leading causes of death in today’s world. They are completely preventable and manageable to a great extent if one follows a sensible lifestyle with a regimen of healthy exercise in daily life. I have divided the problem of cardiac function into categories: disorders of circulation (ischaemic heart disease); disorders of muscle function (cardiomyopathy); disorders of nerve conduction (ventricular ectopic beats).

Ischemic heart disease (IHD) IHD is a very common cause of ill health in our world today. With unhealthy lifestyles, it has increased in its incidence. Science is, in its own way, trying to tackle the situation. We need a fresh approach to the entire problem and in the next few pages I have discussed in detail this disorder which is very easily manageable. I have dealt with the yogic management of IHD separately, as it is a very important problem in today’s health arena. IHD is a condition in which the heart muscle receives inadequate blood and oxygen flow. If the reduction in this parameter is critical, an infarct occurs. An infarct of the heart is labeled in lay terms as a heart attack (MI-myocardial infarction). Coronary artery disease is the most widespread and single most important cause of death in affluent countries. In a majority of cases, death is due to occlusion of the coronary vessels by an atherosclerotic plaque, though other disorders may also contribute.

Causative factors IHD is more common in affluent than in poorer sections of society. This is attributable to the richer diet and lack of exercise or physical activity. The coronary vessels get blocked by an atherosclerotic plaque, and the cardiac muscle suffers gradual reduction in blood flow. Unhealthy lifestyles which include poor eating habits and stressful living, with a high fat diet and no exercise, are the major causes. Even if the diet is healthy, unless regular exercise is performed the circulation in the body can become stagnant. Atmospheric pollution has shown to be an important factor in coronary blockage (European Heart Journal 2006 27(19):2275-2284;doi:10.1093/eurheartj/ehl162). Pranayama has its value here as it can wash out the inhaled toxins efficiently.

Coronary tuning requires fine understanding of our lifestyle, diet and exercise. I have used the word tuning as it conveys a true sense of the nature of sensitivity. As the clarity of reception of a television set depends on fine tuning, the health of the body also needs such delicate adjustments. Before proceeding further the basic question is whether there is such a thing as a totally efficient heart. Many of us do not exercise and still live healthily to a ripe age. Among this group several suddenly die of cardiac arrest. They have had no symptoms at all. When this happens one wonders how such a healthy person could die so suddenly. The answer is that these persons were only apparently and outwardly healthy. Inwardly, the changes in the system must have been slowly taking place, and these cannot be felt unless the disease matures to some extent. Silent narrowing has occurred in the coronary vessels and when it occurs beyond a critical degree, the heart tissues die. The word ‘tuning’ refers to the right and most optimum function of the concerned organ: the heart. How does one get this tuning? There is only one way by which the heart can be kept in the best condition: by exercise; and in this regard yoga is one of the most ideal forms of exercise. The only way to keep the heart healthy is to ensure a constant, fresh blood supply. The practitioner of yoga is so sensitive to minimal changes in body function that perception of the slightest disruption is possible and corrective action taken. Let us compare the ways by which the heart can be ‘conditioned’. The entire repertoire of exercises like jogging, aerobics, athletics, walking, etc increase the heart rate, pulse, blood pressure and oxygen consumption. At this expense, the heart muscle is supposed to be ‘healthier’. In all these exercises, the waste products of aerobic metabolism, such as lactic acid, build up. Fatigue is caused. Fatigue can be in the mind or in the body, or a combination of the two. Usually it is a combination of the two that produces exhaustion. By these systems the heart is kept healthy (in a sense). However, asanas and pranayama do not increase the heart rate or oxygen consumption. All the poses are static and no increase in any of the parameters occurs. Furthermore, energy is built up and one feels refreshed, in contrast to the other exercises where one feels exhausted. Besides, asanas and pranayama benefit the body in various other ways. The mind, which determines stress, is kept quiet. Such stress reduction prevents blockage of arteries, and also relieves anginal pain. In other systems the mind is never silent. We often perform exercises with the portable music systems hooked on! Cellular quieting never occurs. This is the uniqueness of yogic exercise. Conventional exercises are not safe for patients with health problems whereas yoga can be done by anyone, of any age, with any health problem. The use of props makes this feasible. In the annals of medicine a case has been described relating to a twenty-five-year-old marathon runner who had 75% of all three major vessels in his heart blocked and yet could run comfortably. According to conventional, rational thought that exercises improve blood supply to the heart, this person should not have had any blockage in his coronary vessels. But the findings contradicted the analysis. It is surprising that such a person could run a marathon, while another having only a minor blockage was incapacitated. No doubt the area of blockage determines the symptoms. This instance of the athlete having such a poor coronary perfusion and yet performing to his peak capacity shows that the last word about IHD is yet to be said.

Walking as an exercise advised for patients with cardiac problems is not (as is commonly thought) adequately beneficial to the heart. There occurs a rise in pulse rate, oxygen consumption, blood pressure and, at that expense, coronary blood flow is said to improve. In yoga, none of the above parameters rise, yet coronary blood flow is optimized.

Symptoms It is possible that the patient may have no symptoms at all, the reduction in blood flow to the heart being noticed on a routine ECG recording done for a health check up. Such a patient may continue to be in this condition for many years. Alternatively, this patient may also suffer a sudden cardiac arrest. This is an acute MI with death of muscle tissue that suffered blockage of blood flow. This may be sudden and terminal. In many cases, silent narrowing of the coronary vessels may have been occurring. The symptomatic patient is in a relatively better position as there may be time to rectify the situation, unless it is an emergency. Even in the latter condition, with current improvements in medicare, most patients can be saved. The most common symptom is angina, where the patient suffers recurrent chest pain on effort which normally does not produce pain, such as walking on level ground or climbing a flight of stairs. This is due to poor circulation of blood and oxygen to the heart muscle. There is a disparity between demand and supply of blood and oxygen in the heart muscle. At first it happens with moderate to severe exertion and the symptoms are relieved by rest. As the condition responds to medical treatment it is known as stable angina. If no treatment is instituted, the patient may experience pain even with minimal activity as in walking on level ground for a very short distance or a few steps. If diagnosed and treated at the early stages, the prognosis is good. Unstable angina is the condition where the patient suffers chest pain which is difficult to stabilize with drugs. Rhythmicity is lost. Usually, the pain comes on with increase in the work load of the heart, and the symptoms abate with rest. In unstable angina, the pain occurs at rest (Prinzmetal’s angina), which means that the blood flow to the heart is grossly reduced. Emergency bypass surgery may be required. Yet another manifestation of underlying ischemia is lassitude, occasional chest pain often overlooked as being due to wind, giddiness, or the presence of hypertension which brings the patient to the doctor. If the lifestyle does not include proper diet and exercise, the occurrence of IHD should be of no surprise as the circulation of blood stagnates and, in areas of low flow velocity, blocks are prone to form. IHD is easily amenable to treatment either by allopathy or yoga.

Medical diagnosis of IHD An ECG, if taken at the time of anginal pain, may reveal an underlying area of ischemia. A normal ECG does not rule it out either. A stress test is also done, whereby the patient’s heart is subjected to a treadmill bout and the ECG patterns are studied. The patient does the treadmill to the best of capacity being carefully monitored by the physician. As the heart has to work hard during the test, if the

coronary arteries are unhealthy and blocked there is a disproportion between demand and supply of blood and oxygen to the myocardium and this is manifested as chest pain by the patient and appropriate abnormalities are recorded on the ECG. I personally do not believe this method to be accurate. If a person who has never exercised at all is subjected to the stress test, it is only natural that the heart cannot adjust to the strain and suffers ischemia. If the same subject is trained at a certain level of fitness thereafter, the subject can do the same test without strain. On the other hand, if a physically fit subject is found to be unable to perform the stress test, one can consider the situation abnormal. It is not enough to prove that the patient is physically unfit and that the recording of the test shows ischemia; it is obvious that, because of this unhealthy condition, the heart suffers IHD. Hence the stress test is only proving a patent fact and one should not get excited about the positive or negative result of the test. A definitive method of diagnosis is done by the coronary angiogram. This is an invasive procedure and an expensive one. Another method is to inject intravenously a radioactive material known as thallium (an inert material without side effects) into the system and image the heart with the stress test. This gives very good information about the presence of blockages in the arteries. Yet another method is Coronary artery calcium scoring (CT of the heart) which is an advanced, noninvasive test that uses a high-speed CT scanner and software to detect and measure calcium build-up in the coronary arteries.

Management of IHD The conventional management of this condition is by drugs (which have quite a few side effects), an angioplasty (with or without a stent), or by a bypass surgery, if warranted. However, the tendency to operate unnecessarily must be avoided. If the study reveals minor blocks yet the patient is symptomatic, it needs careful treatment. If the blocks are minor and the patient is not symptomatic this also needs attending to, for the same blockage can progress in a few years. On the other hand, a situation may arise when the arteries are badly blocked and the patient can manage the stress test very well. This also needs treatment. Hence it is not only the symptoms, or the extent of blockage, but both which are to be considered in treatment of the disease. Many a time a patient is given drugs as the blocks are minor and advised to review the situation after some time. No specific advice is given about how to prevent the formation of fresh blocks or progression of the current situation. In the meantime the blocks could progress. Drugs used consist of vasodilators which serve to dilate the coronary arteries. The nitrates, particularly isosorbide dinitrate, relieve symptoms. They can be taken orally or by a skin patch in certain circumstances. Side effects include gastric disturbances and headaches which disappear with continued ingestion (but at times can be incapacitating). The other kind of drugs is the calcium channel antagonists which cause coronary dilatation and are effective in stable and unstable angina. They do provide good relief, but drugs like nifedipine have side effects like headaches, gastric disturbances, hypotension, flushing and peripheral edema. Diltiazem is a potent vasodilator of the coronaries. Side effects include decrease in heart rate and giddiness. Clopidogrel is an anti-platelet agent which is very useful to keep the blood from clotting. Well tolerated, the side effects include

bleeding and gastrointestinal disturbances. Aspirin is another anti-platelet agent making the blood more fluid, allowing it to flow freely. Studies show that its usage reduces mortality in patients with ischemia and infarction. However, in the long run, all non-steroidal anti-inflammatory drugs damage a variety of organs, especially the stomach and the kidneys. If we are prepared to damage one organ to save another, then it is worthwhile using nonsteroidal drugs such as aspirin. The arteries are already diseased and, even if not, will not continue to respond to the dilating action over an indefinite period of time. Drugs certainly have an important role to play. An acute attack of myocardial infarction obviously has to be treated by medication, rest, anti-coagulants, etc. While effective symptomatic relief is obtained, it must not end there. I would like to stress that when stabilization has occurred, or the manifestations of the disease are slow and one has enough time to bring in the use of other systems, it must be done. The importance of altering the lifestyle, bringing in the parameters of exercise and a proper diet, discontinuing smoking, should not be underestimated if the blockage is to be reduced, arrested, or, if possible, reversed. Improper advice eventually leads the patient to the table for surgery. Angioplasty is of value in accessible blocks; successful clearance has been achieved in around 75% to 90% of patients. Approximately 15% to 20% of vessels close again within nine months, but repeat procedures are successful. It has been found that the process of removing a block causes release of a chemical known as serotonin which can provide the base for a re-constriction in the artery even after it is ‘cleaned up’. Hence, it is essential to include some method of preventing a recurrence of the block. Nowadays, stents or laser or radiation therapy is used in desperate attempts to prevent blockages. This is absurd as nature, being what it is, will bury the stent in the plaque, which will grow over it again. The circulatory force needs to be kept up. All other measures are not quite the end of treatment, though the benefit gained gives life to the patient. A bypass surgery buys time. While it is certainly necessary, it must be understood that cardiac care should not end there. Preventing repeat blocks due to atherosclerosis in the bypassed area is essential. This cannot be achieved by drugs but only by exercise and dietary changes. Surgery has saved many a life; but about 15% to 20% of blocks close again in the first year, 2% in the next five years and 4% each year thereafter. The patient should be ever vigilant to avoid a recurrence of blocks with consequent surgery. A healthy lifestyle which includes good diet and a disciplined daily routine of exercises cannot be overemphasized. Science has stated what yoga has always advocated: that exercise is beneficial even to patients who have suffered a heart attack (Circulation Research. 2007;100:937-939). So doctors and patients need no longer fear to institute an appropriate exercise regimen in such cases.

Yogic management of IHD It is important that every person over the age of forty has an assessment of coronary blood flow, just as it is sensible for every woman after forty to have a pap smear to be on the safe side. I see no reason why every human being should not have a thallium stress test or an angiogram (if this painful procedure is made easier) done after the age of forty, as one does not know when the disease will strike. Coronary screening is essential—not a stress test, though it reveals information (a patient with

blocked coronaries can still perform the test reasonably well unless the arteries are fairly damaged), but a method that will give direct information about coronary blood flow status. It is not practical to use the technique of coronary angiography on all as it is an invasive procedure. No doubt recent advances in imaging techniques display blockages more clearly, but much work needs to be done on providing better quality of images regarding coronary arterial flow. It is wiser to screen and have baseline data than wait for manifestations of disease. Yoga insists that prevention is better than cure. Patanjali has emphasized that one has to prepare one’s body to take on hidden diseases, i.e., to keep oneself in the peak of health so that disorders can be nipped in the bud. This is particularly useful in ischemic heart disease. Asanas relieve anginal pain very quickly. Asanas and pranayama practiced regularly keep IHD at bay, each of the different poses contributing in its own way. In dealing with the role of asanas and pranayama in IHD, I have discussed their effects in brief with regard to both the heart and the other organs.

Asana, pranayama and the circulatory system An important factor in understanding the pathogenesis of circulatory disorders is that of atherosclerosis. ‘Athero’ refers to blood vessels and ‘sclerosis’ means hardening. This is supposedly a natural process that occurs in all human beings. But to the yogi, this is unnatural. Like a gutter where sediments form on the walls if not flushed regularly, cholesterol plaque forms on the walls of the arteries and blocks them. A body that has atherosclerotic changes is a dull, unclean body that is almost dead. Yoga has always said that mind and body must be kept alert and dynamic. Science has discovered the truth that “hope prevents arterial blockage” (Arteriosclerosis, Thrombosis and Vascular Biology, 1997: 17). Atherosclerosis begins in the cradle. Hence it is important to institute exercises from the age of five though the asanas are practiced differently by children. When the process of atherosclerosis advances, the blood vessels are narrowed beyond a critical degree (fig 160). So strokes, heart attacks and malfunctioning of the organs occur. Essential hypertension, thought to be idiopathic, is because of two reasons: stress on the mind and hardening of the walls of the arteries due to atherosclerosis of aging. Thus, the elasticity of the blood vessels is lost and pressure rises in the blood vessels. Asanas maintain the elasticity of tissues and prevent changes in pressure. What is the role of yoga in this? Yoga is the wonderful solution to all circulatory problems. It works by keeping the two gates of the body—the circulatory system and the respiratory system clean. Regional circulation (blood flow to each organ) reduces as one grows older. There is a fall in perfusion pressure, dampening the flow of blood to vital organs. As has been mentioned earlier, the blood flow to the brain at the age of 65 may be one-third of what it was at the age of 25. Asanas are designed to wash and dry every organ. They work on many physiological principles, one of them being that of reactive hyperemia wherein circulation is re-established after physiological occlusion. (Note that the term physiological occlusion is used, not pathological occlusion.) For example, when we clench our fist tight for a few seconds and release the pressure, the paleness in the palmar area is replaced by a visible redness indicating a greater than normal blood flow to the area. In a sense, the tissue has been massaged. In daily life, when we sit or flex our legs or neck or any part

of the body, occlusion of the circulation occurs in some postures whereas, in others, circulation is stimulated. These are natural adaptations. Asanas are extensions of the same principle. On arising from bed and stretching the limbs in all directions, the invigorating feeling is due to stimulation of blood flow.

Fig. 160 Atherosclerosis.

Asanas do the same. They stretch every nerve, blood vessel, muscle, organ, so that blood supply increases. The regional circulation does not decrease. As long as the blood supply to an organ flows with certain vitality, that organ does not degenerate. With tissue inflammation due to injury to the blood vessels, blood flow is altered, leading to congestion in that area. Practice of yoga regularizes blood flow, allowing fresh blood to come to that area for healing to occur faster. Effect of standing poses Standing poses strengthen the cardiac reserve. These poses, when done properly, produce the effect of having run for some time. But the pulse rate, blood pressure, oxygen consumption, etc., do not rise appreciably. Minimal lactic acid is formed and hence fatigue of the muscle does not occur that easily. Lung capacity is increased by standing poses. As the venous return is higher, varicose veins do not occur (exceptions remain) and the pumping efficiency of the heart is higher. Endurance is built up. All standing poses alternatively increase and decrease the flow of blood to the other organs like the liver, spleen and kidneys. Effect of forward bends Forward bends stretch the posterior surface of the abdominal organs. In Parivrtta Janu Sirsasana, the cortex of the kidneys is flushed with blood. Forward bends soothe the nerves and improve the function of the sympathetic system. Coronary spasms that occur with higher levels of stress are prevented by such asanas. The cardiac nerves are rested. As the tone of the sympathetic system falls, blood pressure and pulse rate reduces. This is beneficial to patients with IHD who in addition suffer elevated blood pressure. Since the body is parallel to the floor, gravity does not affect the heart and blood flows to both

extremities without strain. The sympathetic nervous system is given a tremendous boost of energy so that when these poses are completed one feels extremely energetic and refreshed. Forward bends tend to dilate the chambers of the heart. Effect of back bends A bypass surgery can definitely be avoided if a patient reaches the level of practice of a normal person, particularly in back bends. All back bends stretch the cardiac vessels; so that blood flow increases post practice and blocks cannot occur. It is precisely for this reason that patients with coronary ischemia are initially taught back bends and not forward bending asanas. When angina occurs, if Supta Virasana and Viparita Dandasana are done, it can give good relief. One might argue that resting the body when angina occurs will naturally relieve the pain, for the strain on the heart is removed. But what about the condition called Prinzmetal’s angina that occurs even when at rest? Asanas also place a certain amount of stress on the coronary vessels, but no asana can cause angina. The exact mechanism by which asanas provide relief is yet to be ascertained. I have injected myself with thallium and performed Viparita Dandasana and Setu Bandha Sarvangasana to assess coronary flow. The interpretation was very difficult as we are not used to those changes in picture patterns. However definite changes did occur. Back bending poses have a tremendous effect on the coronary flow and force of contraction of the heart. The massaging force increases intra thoracic pressure and the natural outcome is called a ‘physiological bypass’. The quality of contraction of a muscle fiber is directly proportional to the initial length of the muscle. As all back bends stretch the thoracic organs, venous return is enhanced. This improves coronary blood flow. Underlying ischemia of the heart is treated. The controlled rise in intra-thoracic pressure stimulates the cardiac muscle and the septum, the quality of contraction of the heart improves, and the quality of blood pumped out increases. Back bends strain the heart healthily. This kind of static strain helps improve coronary flow over a period of time just as walking is used for cardiac patients. Exercise improves the lumen of the coronary arteries (Circulation. 1993 Apr;87(4):1076-82). Back bends are the aerobics of yoga and hence the strain can be considerableyet safe as it is static. It may be stated tentatively that it is possible that over a period of time the coronary arteries improve its vasodilatory capacity with yoga due to a few or all of the below mentioned mechanisms that have been postulated for other systems of exercise. Four broad types of possible mechanisms for the beneficial effects of exercise have been identified. The first is an anti-atherogenic effect that includes an improved lipid profile (increased HDL and decreased LDL and triglycerides), loss of body fat, increased sensitivity to insulin, and reduced blood pressure. The second is a reduced risk of thrombosis due to favorable changes in platelet adhesiveness, fibrinolysis, fibrinogen levels, and blood viscosity. The third is a reduced risk of myocardial ischemia due to a decreased myocardial oxygen demand and an increase in coronary blood flow during exercise. During difficult back bend practice the heart is made to adapt to manage with available diaphragmatic excursions and availability of O2there of. Hence normal day to day activity is easier.

Supta Virasana. The pillow helps avoid strain to the accessory muscles of respiration in the neck and rests the heart.

Viparita Dandasana on rack with slanting plank. The position of the body on the prop promotes cardio-respiratory health.

The increased coronary flow results from an increased vasodilator capacity. Also, recent evidence on reversal of endothelial dysfunction and improved exercise capacity with low-intensity exercise training in patients with chronic heart failure may be quite relevant in the primary prevention of IHD. The fourth mechanism is a reduced occurrence of lethal ventricular arrhythmias due to increased vagal tone (vagal tone definitely increases with yoga practice) and reduced adrenergic activity during rest and exercise. The reduced adrenergic activity is also a net effect of yoga as it calms the entire system and induces stillness. Such adaptations of the autonomic nervous system with increased physical activity may account for an overall reduction in the risk of sudden death with habitual exercise. It is postulated that yoga can work along :

1) better coronary flow due to removal of sympathetic stress 2) vigorous 2 hour yoga session can improve lipid profile patterns 3) improved oxygenation patterns due to pranayama. The asanas also correct the position of the pericardial sac and, if the heart is excessively dilated, give a lateral compression restoring the original chamber size. This has been confirmed by echocardiography. Therefore, back bends are a must in cardiac problems. In back bends like Urdhva Dhanurasana, Viparita Dandasana and Kapotasana, a stretch of the liver and spleen occurs which moulds itself to the geometric shape of the body. As the liver is a very soft, highly vascular organ, it is easy to see and feel the effect of the asanas on the organ. The flow of blood to the frontal lungs is greatly increased in all back bending asanas (post practice). Elasticity of the tissues is maintained so that the vital capacity of the lungs does not decrease with age. Due to increased blood flow to the lungs, oxygen uptake is stimulated. There will be no areas of hypoperfusion in the lungs of a yogi. In a normal human being many areas of the lungs have nonfunctioning capillaries where blood flows but no gas exchange occurs. These polarities are abolished by asanas. As the lungs are always kept warm, there is resistance to climatic changes which is beneficial in chronic lung ailments like asthma and bronchitis. A healthy lung leads to a healthy heart. If the lungs perform efficiently with excellent intake of oxygen, the myocardium gets the benefit as the oxygen rich blood flows into the heart. Effect of inverted poses Inverted poses drain all the venous blood from all organs, revitalizing them with fresh blood. An important effect of inverted poses is on the vasculature of the legs. The constant strain of gravity and the effort needed to pump the blood upward to the heart is removed and rest is given to the entire musculature and nerves of the leg. So the tendency to varicose veins is checked. The small muscles inside the calf, which continuously pump the lymph up the body, get rest.

Dog pose with rope. The entire weight of the body is taken by the rope so that there is no strain in holding the pose and the benefits are obtained easily and quickly.

Shoulder stand with chair is medically safe and relief from angina is experienced very soon.

Head stand with rope. Inverted poses help the flow of blood to the heart, penetrating to the level of the microcirculation.

The blood flow to the heart gradually reduces with age. Changes like loss of pumping capacity and palpitations occur. If critical narrowing occurs, an infarct can result. Practice of inverted postures reestablishes the blood flow to the heart and penetrates to the level of the micro circulation. The coronary cells cannot die prematurely. Rope Headstand removes cardiac fatigue by relieving the strain of G force. Apart from the energy, the cerebral nerves are rested in this pose and one feels soothed with revitalization of the centers in the brain that control the heart. Often, an infarct often is due to atherosclerotic plaques. Unless the coronary arteries are flushed with blood every day they become clogged. It is easy to flush the muscles with blood but it is difficult to flush the coronary arteries with blood. For this, yoga recommends inverted poses and back bends. All inverted poses condition the heart by one main law in physiology: Laplace’s law. This states that

whatever be the amount of blood the heart gets, it has to pump out the same quantity. As the venous return is higher in inverted poses, the contractility of the heart improves. Blood flows to the brain without strain. The heart is rested. The constant stretch of blood distending the chambers of the heart is removed as the body is inverted. The coronary arteries receive an enhanced flow of blood as venous return is better. Setu Bandha Sarvangasana is very beneficial to the heart, with the ejection fraction rising to 88%. Regular conditioning of this nature is good for the heart. Cardiac efficiency is kept up even as age advances. Sirsasana and Sarvangasana give rest to the heart due to inversion. In Head stand, the heart is rested and energized. Vital parameters are maintained in all inversions. Effect of resting poses Resting poses such as Viparita Karani, Dog pose with the rope, Setu Bandha Sarvangasana on the bench have the same effects as back bends. They do not produce even the slight strain induced by practice without props. As the body is rested, the pose can be held for a long time and hence the effects are pronounced. The heart being rested, which rarely happens in daily life, is highly energised.

Setu Bandha Sarvangasana on box and bench. Cardiac efficiency is maintained even as age advances.

Urdhva Dhanurasana on ladder stool enhances pump efficiency and relieves angina rapidly.

Viparita Dandasana on a chair with head rest improves cardiac contractibility and positioning.

Effect of twisting poses In twisting poses, squeezing of the organs removes a good quantity of blood from them. When the pose is released, fresh blood rushes in with tremendous force, keeping the blood vessels clear of blocks. Twisting poses work on the lateral walls of the heart. The diaphragm is squeezed and hence the endurance of the heart increases. Any adhesion between the heart and the surface of the diaphragm is released. Effect of pranayama As a deep inhalation is done, enhanced venous return occurs along with better lymphatic drainage. The rhythmic up and down movement of the diaphragm massages the abdominal organs, increasing their circulation and efficiency. Blood flow changes in the kidneys, permitting better filtering action of water and solutes. The color of the urine changes with regular pranayama practice. Changes in coronary flow occur during pranayama, allowing better blood to flow into the coronary vessels (due to reduced sympathetic tone). The input of healthy blood into the lungs increases, allowing better uptake of oxygen and build up of adenosine triphosphate (ATP) molecules at the cellular level, which is the source of energy to the cell. Blood flow in the brain can change with pranayama where a prolonged exhalation soothes the neurons by increasing the blood flow. Quieting of the mind during pranayama is very beneficial to a cardiac patient, reducing stress on the sympathetic nerves. This can go a long way in preventing a sudden attack in times of emotional stress. The system being stronger, sudden spasm does not occur in the coronary blood vessels. Relaxation of the nervous system allows excellent perfusion of blood with the coronaries relieving oxygen starvation of tissues. Angina vanishes rapidly after pranayama practice. It is the only science that delivers oxygen directly without strain and facilitates storage at the cellular level. As mentioned, washing away of free radicals by pranayama at the cellular level is very important. Asanas improve blood flow, pranayama the oxygen content. After a few months of pranayama practice, drug dosage can be tapered.

Setu Bandha Sarvangasana on the little horse stimulates the heart without strain.

In this manner, a diseased heart can be made to function normally. How wonderfully would the function of a normal heart improve! Blockage of the coronary vessels would seldom occur nor would changes in size or rhythm of the heart. Even when the disease is well established, it is possible to treat cardiac problems by the use of non-pharmacological means like yoga. In some cases, a reduction in the block and even a re-opening can be demonstrated. It is certain that if the heart is not very diseased when the patient starts asana practice, no further deterioration will occur. To avoid a bypass is not difficult; alteration of the lifestyle with regularity of yoga practice seems to be the problem for most patients. As the patient improves, advanced versions of these asanas, as well as others of a different nature, can be introduced. All these should be learnt under the guidance of a competent professional. Yoga is also excellent in preventive therapy. According to the science of yoga, the body inevitably degenerates if not protected. Hence the rule is to practice asanas and pranayama every day so that the quality of blood flow in the body will be maintained. The advice regarding diet is also clear. A vegetarian diet, with very little fat, is recommended. And with yoga there will be no side effects to worry about. Some of the following asanas are used in the treatment of coronary ischaemia: Supta Virasana, Adho Mukha Svanasana, Viparita Dandasana, Sirsasana and Urdhva Dhanurasana, Sarvangasana, Setu Bandha Sarvangasana, half Halasana and Viparita Karani.

Disorders of muscle function I would like to highlight a single disorder, namely dilated cardiomyopathy, since it is a controllable condition (unless the myocardium is grossly damaged). ‘Myo’ refers to muscle. Cardio-myopathy refers to a primary muscle disorder of the heart. The cardiac muscle becomes flabby and weak, and fails to pump effectively.

There are a variety of specific agents (such as nicotine and alcohol) that are known to cause this disorder. In some cases the cause is unknown (idiopathic). Underlying ischemia of the heart is a coexisting condition. It is important to initiate drugs to boost the failing heart. In addition, it is necessary that the cardiac muscle be stimulated, thus taking care of the root of the problem. The diagnosis is made by both subjective and objective methods, the former being symptoms like breathlessness on effort, feeling breathless on lying down as, in the recumbent position, fluid tends to collect in the lungs. Swelling of the body and feet, accumulation of fluid in the abdominal cavity are some other manifestations. Regarding the objective methods, ultrasound imaging of the heart and a MUGA scan with a dye injected intravenously are useful methods of diagnosing the condition. The flabby heart is easily picturised.

Medical management of cardiomyopathy The medical management includes diuretics that are used for reducing water and sodium levels in the body, vasodilators to reduce strain on the heart allowing it to pump (if the blood vessels are a little dilated, it is easier for the heart to pump), and the use of digitalis which helps the heart muscle to pump. The normal biochemical cellular changes of muscle contraction in the muscle cells are antagonized by this drug and this retains the chemicals needed for the heart to pump. This is very helpful but it must be remembered that this is an unnatural action (equivalent to flogging a tired horse) and as soon as the clinical condition permits, possible alternative methods must be sought. Other agents that enhance cardiac contraction, like doubutamine, are useful, depending on the case.

Yogic management of cardiomyopathy Yogic management of such a disorder is a very effective form of treatment. Yoga can supplement western medicine in this situation. Asanas improve and maintain the pumping capacity of the heart. After stability is achieved and cardiac failure alleviated by drugs, if asanas are introduced (as soon as possible) best results are obtained. All back bending asanas are invaluable and props are essential. Later, props can be withdrawn. After initial training, inverted poses are helpful to rest the heart muscle. Setu Bandha Sarvangasana is beneficial to this condition. The box and bench are used initially an useful to alter chamber size and is done with pillows to support the dorsal spine. Regularity of practice is a must for consistent results. Shrinkage of chamber size may require several months. Pranayama constantly changes the shape of the heart. As a deep inhalation occurs, the right ventricle (RV) enlarges and pumps out more blood while the left ventricle (LV) shrinks and the output falls. During exhalation the changes are reversed. Such constant, systematic changes in LV and RV size are very useful for patients with a dilated or shrunken heart. Depending on the size, either prolonged inhalation or prolonged exhalation can be done. Normalcy of chamber size cannot be achieved with the addition of yoga alone but it can strengthen the heart pump.

Disorders of nerve conduction (arrhythmias)

This is another common disorder: the VPC (ventricular premature contraction or ventricular ectopic beats), which may be ‘benign or malignant’, meaning that the condition can run out of hand. The word ectopic means ‘out of place’ and in this problem, the sinus node does not set the rhythm of the heart as in healthy persons. There is a focus in the left ventricle which prematurely initiates a cardiac contraction. The rhythm of the heart frequently changes. There are several causes for this situation, but in most a specific cause cannot be identified. Aggravation of irregular beats with stressful situations is well known. As this beat is premature, there is a long compensatory pause allowing the heart to recover from the premature contraction, before regularizing itself. Usually, the irregular beat can be rectified with exercise, which in some alters the autonomic nervous control, (and in a lesser number of cases makes the situation worse). Ventricular ectopics that are benefited by exercise are more common. There are many other types of rhythm disturbances which are beyond the scope of this book.

Medical management of ventricular ectopic In general, the treatment of rhythm disturbances requires drugs that block nerve conduction in the ramification of nerves in the heart muscle. There are many classes, (class 1 to class 4) each with its own side effects. The class one (quinidine, procainamide, etc) and class three (amiodarone, bretylium) drugs are useful to treat ventricular ectopics. Excessive dosage can itself create rhythm disturbances. Hence, according to medicine, treatment of asymptomatic ventricular ectopics is not warranted. Yet a healthy heart should not suffer any disturbance and one has to bear this fact in mind. Newer and more powerful drugs are available albeit with more side effects.

Yogic management of VPC Practice of asanas can correct the condition as they achieve control over the cardiac plexus. The removal of stress, both physiological and psychological, on the heart and the entire system abolishes the disturbances. All categories of asanas are valuable. In my experience, practice of pranayama removes the rhythm disturbances almost at once (prana also being nervous energy). Regularizing this energy corrects all nervous disorders in the body. This correction of rhythm can be easily observed by ECG recordings. Pranayama is superior to all involuntary processes in our body. The heart rate is considered an involuntary function, but a practitioner of pranayama can reduce or increase it at will. Hence the socalled involuntary mechanisms can be made semi-voluntary. One can thus see what a sensitive system our human body is, and how easy it is to keep it in order. Yet, one fails to do so, thus inviting various diseases. Healthy circulation and respiration, allowing no aging of the cells, are the keys to a healthy human body.

Essential hypertension (EHT) Essential hypertension is concomitant of competitive, fast-paced modern life, in the sense that a traditional, rural, relatively passive lifestyle is more conducive to cardiovascular health. For that

reason, villagers in India have far lower incidence of high blood pressure than urbanites. In the US, on the other hand, one out of every 20 adults is said to have hypertension and half as many more are in an early stage of it.

Causative factors The exact cause is still elusive. Psychological, physiological and environmental factors are only three of the many factors that lead to high blood pressure. In fact, despite rapid scientific advances in the understanding and treatment of high blood pressure in recent decades, in most cases we still do not know what causes high blood pressure. A common misconception is that aging is a cause for hypertension. It doesn’t always, though the universal average for the onset of hypertension is the late thirties. Sometimes even babies are known to suffer from it! Short, stocky, overweight people and those who are tense and excitable are especially susceptible to hypertension; emotional conflicts are also a cause. At present the role of the mind in causing high blood pressure is not in doubt. This has been borne out after systematic studies. But yogic science has always stated that the mind is the cause of stress and this has been purely intuitive. Medically, constant stressful discharge in the hypothalamo- cortical pathway is known to keep the blood vessels under a tighter control, thus elevating the pressure. The circulatory system in our body is like a series of pipes endowed with a certain potency to allow blood flow to different organs. This potency is under multi-factorial influences: race, diet, stress exercise, etc. There are receptors (alpha) in the blood vessels the stimulation of which constricts the blood vessels, and others known as beta the inhibition of which opens the lumen reducing the blood pressure (see section on functional anatomy of heart). The hormone renin is secreted by the renal cells. This is elevated in 15% of hypertensive patients. In about 20% of EHT patients, renin levels are low. Renin secretion is influenced by sympathetic stress which, in turn, means the stress faced by the body and the mind. Ultimately, it is the mind that influences the body, the effect being mediated through the sympathetic nervous system. Hence renin secretion may well be under mental influences. Renin reacts with a chemical known as angiotensinogen and this sets off a series of chemical changes, producing an end product known as angiotensin which causes vaso-constriction and elevated blood pressure. This situation is also influenced by the hormone aldosterone, which retains salt and water through the kidneys, aggravating the condition. The role of salt in influencing blood pressure has to be individualized during therapy.

Symptoms Usually, essential hypertension has no symptoms and is found on routine examination. The normal blood pressure under resting conditions should be 120/80 mm of mercury. Both the systolic and diastolic pressure can be affected. Both have to be made normal with treatment. The level at which the systolic pressure should be treated is 140 mm and the diastolic 90 mm. Pressure of 130 to 135 mm systolic and 85 to 88 mm diastolic are labeled as high normal. However recent dialogues in the field have labeled even 120/80 as pre-hypertension. I personally disagree with this study or concept. If blood pressure is recorded in the morning as soon as the patient wakes up, this would reflect the

real condition, as the overnight rest should have recuperated the system. Measurements made in clinics are of course valuable but the element of stress, travel and other factors should be borne in mind. Systolic pressure is the measurement made when the heart is contracting and the rest of the body gets its blood supply. The heart muscle itself is fed with blood only when the heart relaxes (diastole); for, during systole, the muscular forces press on the coronary arteries, reducing its own blood supply. Hence if the diastolic pressure remains above 90 mm, coronary artery filling will be jeopardized. Hence a hypertensive patient can suffer a myocardial infarct. If the sympathetic stress is reduced the diastolic pressure is reduced and coronary filling is normalized. High blood pressure is a serious condition and requires prompt attention because it works insidiously and brings about other cardiovascular and renal disorders (stroke and renal failure). The pressure can remain stable or fluctuate. The latter is a dangerous situation known as labile blood pressure. Any sudden rise in pressure can produce a stroke. When blood vessels get constricted, the heart must work harder, and a time comes when its own coronary arteries can no longer nourish the heart; then heart disease develops.

Medical management of EHT In treating this problem medicine relies only on drugs (nifidipine, amlodipine minoxidil, hydralizne, etc) that dilate the blood vessels thus reducing the pressure. These drugs may either act directly on the arterial wall or prevent uptake of calcium in vascular smooth muscle which normally constricts the blood vessels. Side effects include increased heart rate, angina, flushing, headache, etc. Other drugs known as diuretics (thiazide group, fursemide, spironolactone, amiloride, etc) remove water and salt from the body and this volume depletion sets off some adjustments by the endocrine glands that reduce blood pressure. Side effects include aggravation of a diabetic state and alteration of electrolyte levels. Another category of drugs works by inhibiting the activity of the sympathetic nervous system, both in the central areas (clonidine and methyldopa, centrally acting in the cortical centers) and in the periphery, and thus reduces the pressure. But the nervous system cannot be controlled so easily in the peripheral areas or the central. Side effects of centrally acting drugs include postural hypotension, dry mouth, rebound hypertension, sedation fatigue and impaired ejaculation. In the group that acts at the periphery, reserpine acts on the nerve endings at the periphery and can cause depression of general drive, nightmares, nasal congestion, dyspepsia, dry mouth, bradycardia (slow heart rate) and postural hypotension. Drugs that act on the alpha receptors (prazosin and phentolamine) cause headache, giddiness, weakness, tachycardia, etc. Drugs that act on the beta receptors are commonly known as beta blockers (propranolol, atenolol, labetalol, timolol) and these cause dizziness, bronchospasm, constipation, bradycardia, interference with counter regulatory hormones that are released in the blood during hypoglycaemia to increase blood sugar. Of course, highly selective beta blockers are better tolerated. ACE inhibitors inhibit some enzymes which convert angiotensinogen to the active form which causes

blood pressure. Side effects are fever, loss of taste, kidney affliction and a host of other reactions. In general, this class of drugs is well tolerated. ACE receptor inhibitors are yet another class of medication which are also well tolerated. Yet another set of drugs tries to work on the mind during the dream phase (tranquilizers) and prevent the rise in pressure. But on the practical side, the vasodilators give the best response. In some cases the pressure remains high, not responding to any medication. Many patients fall into this category over the long term if lifestyle changes are not introduced. It must be understood that the mind is very powerful and can overcome the effect of many a drug. In this respect, a good example is the variable response of sedatives. One patient may require a single dose of the drug and another, several. But the brain is the same, the drug is the same. This shows that mental forces are different in different people and this requires understanding. So long as the patient continues to remain stressed and does not learn to relax, the blood pressure does not get controlled. Medicine treats patients as though they are fixed entities and pumps drugs into their system. But the body and mind are never the same from day to day and the challenges vary from day to day; so how can the therapy be so mechanical? Drugs are certainly useful in reducing pressure, but it must be realized that they are not the linchpin of treatment in the long run. The patient must be taught to live a stress free life.

Yogic management of essential hypertension Yoga is an excellent means of treating high blood pressure. As essential hypertension begins in the mind, yoga is of prime value. However, weight loss is essential for yogic management to be of use, and only dynamic exercises can reduce weight. Yoga can be practiced side by side with weightreducing exercises, as yoga alone can prevent vascular complications due to its massaging effect on the arteries. Asanas make the arteries and capillaries, (which are influenced by the mind) elastic allowing more blood to flow into various areas, resulting in better relaxation of those tissues. The dilating and constricting capacity of the arteries is restored (which is lost as one grows older due atherosclerosis). Yoga works both on the nervous and the circulatory systems in essential hypertension. Once the nervous system is kept relaxed, the blood pressure is kept under control. The right approach would be to make attitudinal changes in day-to-day life, and learn how to relax the neuro-physiological system (which happens in yoga) and thus control the high blood pressure. Considering other exercises like jogging and cycling, the blood pressure initially rises and in the post exercise period reduces to below the level for the subject. This reduction is more evident in borderline hypertensives than in normotensives. This only proves that the correct initial management of essential hypertension ought to be regular exercise. The alterations in such cases are thought to be due to changes in the sympathetic nervous system. The sympathetic nervous system is always set on a higher level of charge in hypertensives. By the practice of yoga the tone of sympathetic discharge is brought down. Even in a normal person, blood pressure varies from the standing to sitting to lying down positions and with the state of the nerves; it can therefore be seen how asanas alter blood pressure. Yoga is like sleep, a conscious sleep. In sleep the nervous system recoups itself; the same happens in yoga. There is yet another difference. In sleep

the subconscious mind is still active and the nerves are still tense. In yoga every part of the nervous system is kept passive and the relaxation of the nerves is far better. The state of nerves in a hypertensive is one of overuse and decreased excitability. Excitability means the ability to transmit an impulse. In a hypertensive, the nerves are exhausted and overstrained. As the excitability of the nerve is inversely proportional to the degree of activity, yoga restores the elasticity of the nervous system. A proper sleep pattern is essential for all, particularly for a HT patient. A hypertensive should retire by 9.30 pm and rise by 5.30 am. The delicate biorhythm in the body which influences the neuro-endocrine circuit should never be upset. It is not only the number of hours, but also when one sleeps that matters. If the biological clock in our body is upset, the damage is very difficult to reverse. Forward bends are the linchpin of yogic management without which the pressure never normalizes. Fluctuations of blood pressure are controlled by these poses. When these poses are practiced, the thoracic cage is brought parallel to the ground, and the heart slows down as there is no strain to push the blood against gravity to the brain. With decrease in the heart rate, the cardiac output also reduces. These poses increase the vagal tone and the excess sympathetic tone is reduced. There is then a decrease in the tone of the vasomotor centre in the brain (which controls the tone of the arteries) and blood pressure drops. The use of the elasto-crepe bandage helps the facial muscles to relax and is essential. When this occurs, the muscles of facial expression lose their grip on the organs of perception and relaxation occurs in the frontal brain. The bandage also helps to relax the ocular muscles which are always tense in many patients. Rest is given to the eyes and the mind. If these two are relaxed, the pressure is controlled. As the mind becomes completely introverted in forward bends, the body processes are brought to a very low level of functioning. This approach of treating the problem of essential hypertension is holistic. Even if the patient is stiff, adopting a simple cross-legged position and stretching the spine forward to rest on the pillows provides excellent results. Gradually the forward bends can be mastered. Proper timing is very important. The completion of forward bends should take at least 30 minutes, followed by other postures.

Pawana Mukta Virasana with pillow. Forward bends are central to the yogic management of hypertension.

Cross-legged forward bend with pillow. Fluctuations of blood pressure are controlled by forward bends.

When Uttanasana and Adho Mukha (with the head rested on the pillows) are practiced, the blood flows more freely into the aortic arch and the carotid sinus. This extra perfusion into these volumesensitive structures (they have nervine receptors that sense blood pressure changes with respect to posture) inhibits the vasomotor centre and blood pressure drops. Adho Mukha Svanasana maintains the elasticity of the diaphragm and hence the pressure is controlled. Setu Bandha Sarvangasana rests the brain and again the cortical centers are rested. The mind is kept focused internally. One of the most important asanas for this purpose is Viparita Karani wherein the sympathetic tone is reduced quickly. Regular practice of this asana keeps the blood pressure under control. In cases of atherosclerosis as a cause of isolated systolic blood pressure in the elderly, the practice of asanas maintains the elasticity of the blood vessels and hence the resistance is not raised. Standing poses are to be practiced initially with the body supported against a wall to prevent strain. These poses work like aerobic exercises in their effects in normalizing the blood pressure as explained above. Inversions should be practiced later. To begin with, half Halasana is mastered, preceded by forward bends. Later Head stand on the ropes (this does not increase the systemic blood pressure) and Shoulder stand are to be practiced. In hypertensives the blood vessels of the brain, lose their auto regulatory capacity. Auto regulation means that whenever the pressure in the cerebral circulation increases, the surrounding cerebrospinal fluid bathing the brain clamps down on the blood vessels, preventing rupture. This sensitivity is lost and can only be restored by asanas; particularly Head stand in which blood directly flows to the brain. But forward bends prepare the patient for this. As explained in the previous chapters, the pressure in the cerebral arteries does not increase in the inverted poses. As the hypertensive patient cannot perform these asanas in the beginning to that level of comfort, and as the elasticity is lost, forward bends and half Halasana bring back elasticity to the cerebral arteries. Then Head stand provides the seal of stability. If the elasticity of the vessels is not restored, the

hypertensive patient can suffer a sudden stroke if the blood pressure is of the fluctuating type. Drugs do not prevent such rises in pressure as their action is mechanical and the factor of the mind and emotions is not considered. The system will respond tardily to the drug in the long run, necessitating an increase in the dosage. Asanas do not have the side effects that drugs induce as it is a natural system. Hence the sensitivity of the body is not destroyed. As the patient improves, passive back bends can be introduced. Viparita Dandasana rests the medulla oblongata which has centers that control the blood pressure. A tense individual has a tense diaphragm, a tense circulation and a high blood pressure. Back bends release tension in the diaphragm. Viparita Dandasana done on the rack does not increase the blood pressure, but if done independently it can be uncomfortable for hypertensive patients. Later, in Savasana, prolonged exhalation with normal inhalation stabilizes the sympathetic system. Inhalation is stimulative to the brain, whereas exhalation relaxes the sympathetic nerves and the blood pressure is thus controlled.

Viparita Karani on bolster rests the body. The active pose, without the prop, should not be done when suffering fatigue.

The specific asanas prescribed for treating hypertension have to be performed only under the guidance of a professional.

Savasana with weight on forehead. In this pose, prolonged exhalation with normal inhalation stabilises the sympathetic system.

Role of pranayama A patient cannot practice breathing in the early stages of the disease as the body and mind are not toned. But after asanas have elasticized the body in different areas, the same is possible. Pranayama greatly influences the circulatory system. With each inhalation and exhalation, the output of blood flow to the body varies. This changes the blood pressure. In prolonged inhalation (never done by normal people) the right ventricular (RV) output increases and left ventricular (LV) output falls. In exhalation, the reverse occurs. Due to the increase in duration of inhalation and exhalation, significant pressure changes can occur. The emphasis on inhalation or exhalation depends on blood pressure being high or low. The overdrive of the sympathetic nervous system is most amenable to reduction by the practice of pranayama. The elasticity of the aorta and major blood vessels is well maintained. After a 30-minute session the blood pressure reduces and remains so for several hours. Constant conditioning over several years helps regulate the pressure. There are special types of pranayama for high blood pressure. The steady rhythmic breathing helps control the autonomic system. As the breathing rate reduces, the stress on the body is reduced. The hibernative state removes the accumulated stress. All this happens over a period of time. Viloma pranayama type 2 is very suitable for high pressure. A bandage is always used. In this method, inhalation is a continuous process and exhalation is interrupted in gaps of two seconds. About six breaks of exhalation are performed. The use of the bandage is essential and the patient must be in Savasana with the spine supported by a pillow and the neck supported, thus relaxing the accessory muscles of respiration. In the carotid arteries, the walls of which have baroceptors that adjust reflex changes in blood pressure, the practice of raising the dorsal spine and lowering the head into the chest with prolonged breathing patterns massages these receptors and lowers blood pressure. If the dorsal spine is not supported, the rib cage never relaxes and breathing remains tense. As the mind and senses are withdrawn, pressure drops. Without the bandage, withdrawal of the senses never occurs. The relevant asanas needed include: Savasana on bolster; Supta Virasana on bolster; Virasana (bending forward), Setu Bandha Sarvangasana on bolsters; Adho Mukha Svanasana with rope and bolster; Janu Sirsasana and Pashchimottanasana with bolster, simple cross-legged position and bending forward; Head stand on rope; Viparita Dandasana on rack; Sarvangasana on chair; half

Halasana on bench; Setu Bandha Sarvangasana; Viparita Karani and Savasana with weights and Shanmukhi Mudra.

Pulmonary Diseases Pulmonary diseases are on the rise due to the extensive iatrogenic pollution in our world. Unless a global commitment is undertaken to control pollution, the incidence of patients suffering from such disorders as listed below will be on the rise.

Bronchial asthma Asthma is a lung disorder characterized by hyperirritability of the airways to a variety of stimuli. The prevalence is worldwide. The disease is broadly classified into two categories: allergic asthma often associated with a positive history of wheezing, urticaria, eczema, etc., and a positive test to skin antigens; and idiosyncratic asthma with no positive history but symptoms developing after an initial upper respiratory infection. A positive family history is often present in the individual patient.

Causative factors The essential feature is widespread inflammation of the airways. This is in response to a multiplicity of stimuli: drugs, allergy, environment, occupations infections, food and exercise related and emotional. A variety of drugs like aspirin, beta blockers (as beta stimulation dilates airways) like those used to control hypertension, some coloring agents, an assortment of products like sea food, salads and fresh fruit contain preservatives and other chemicals that cause wheezing. Environmental airborne factors at any time of the day irritate the lining. Smoke is one of the principal irritants. During intense aerobic exercise, a person often breathes through the mouth and the humidification of the inhaled air by the nasal passages and the sinuses is lost. This results in thermal cooling of the air that reaches the distal airways, causing wheezing. Occupational factors like exposure to strong smells, leather, cotton, etc., are all well-known agents that provoke wheezing. Virtually any agent can cause wheezing. Infections cause wheezing and this is due more to viruses than to bacteria. Emotional stress increases the parasympathetic tone and provokes wheezing. The mechanism by which the spasms are triggered is not fully understood, but there is an antigen antibody complex which releases chemical mediators of inflammation and hypersensitivity, bypassing the cellular defense mechanisms. Such chemicals include histamines, prostaglandins and a variety of other substances. This allergic response is mediated by T and B lymphocytes. The hallmark is reduction in airway diameter due to edema, mucus plugs, and smooth muscle constriction. Air trapping occurs. Hypoxia is a universal finding during acute attacks. There is carbon dioxide retention

and metabolic acidosis results.

Symptoms The disorder can be acute or chronic. An acute exacerbation of a chronic condition is also possible. The symptoms consist of a triad of cough, wheezing and breathlessness (dyspnea). They can be present singly or in varying combinations. A small amount of sputum, typically sticky, is produced. Ventilatory assistance may be required if the spasms worsen. Occasionally, death supervenes. No single test is conclusive of asthma; but a clinical conclusion is well assisted by pulmonary function tests. This shows reduction of various parameters. An adult can suffer the problem in middle age for the first time-the so-called adult onset asthma. Hence it is good to practice yoga to be fit all the time.

Medical management The treatment consists of oral drugs or the use of different systems of inhalers which deliver the drug by a fine mist into the airways. The oral drugs stimulate the beta receptors in the lining of the bronchial tree. They dilate the airways by chemical changes through the sympathetic nervous system. Since the sympathetic tone is reduced in asthma, drugs that provoke this system are necessary. Drugs like the methylxanthines (theophylline) produce dilatation through certain chemical mediators. Salbutamol is a drug that works along the sympathetic nervous system, stimulating the beta receptors. Cromolyn sodium prevents the mast cells from releasing the chemicals of an allergic reaction. It is preventive, not curative, in action. Newer drugs which provide quicker relief are available, but none is natural in its mode of action. At the end of the drug list are steroids which reduce airway blockage by their anti-inflammatory action. Depending on the clinical condition intravenous therapy is used. Most of the drugs have side effects like tremors, palpitations, sweating, ectopic beats and gastric disturbances. This is related to the severity of the disease and, therefore, the frequency of drug usage. The tremors are due to over stimulation of the sympathetic system through the beta receptors. The gastric irritation is due to a direct effect on the lining of the stomach. The incidence of side effects also depends on the individual susceptibility of the patient to the drug. However, the necessity of drugs in dealing with a problem like asthma cannot be understated. It is not possible to predict whether the disease will worsen or not, as the aggravating conditions are multifactorial. Moreover, if the patient is in a state of tense anticipation of an attack, it is difficult to reduce the dosage. Regardless of the pattern of attacks, an asthmatic must be taught how to relax the mind. Asthma is described as psycho-somatic as the mind is linked to the respiratory tree, and stress upsets its delicate chemical balance. Though most asthmatics can never really be completely free of the disease, it is possible to strengthen the system by the addition of the parameter of yoga to the regimen of treatment. In some cases, the practice of yoga should be continued along with medication for many months. In others, it may be possible to discontinue medication in a short while. If an asthmatic is able to ensure stability with minimum dosage of the drug aided in the greater part by the practice of yoga, it is certainly an

achievement in today’s polluted world. Many asthmatics feel better if they change their habitat. This may entail a different climate in the same or a different country. So long as they live in a different place, their attacks may be highly infrequent. For example, when an asthmatic from India migrates to the American continent, the attacks reduce and almost disappear. On return to India, the moment they alight from the aircraft, the spasms begin due to the high humidity and pollution in many states.

Yogic management Yoga is very useful in the treatment of asthma as it primarily works by stabilizing the autonomous nervous systems. According to yoga, quietude in the body always stabilizes irritable responses. The parasympathetic tone is in excess in asthma; exercises always help balance the autonomic tone by raising the sympathetic. It is possible to change the very responsiveness of the body. It is a matter of training. Asanas do their part by helping to ease the congestion in the lungs. This promotes relaxation of smooth muscle and better oxygenation. The change, however, does not happen overnight, as asthma is a chronic disorder and irritable responses take time to stabilize. The earlier the asthmatic begins yoga the better the response. Constant practice is required to change the sensitivity of the body. The practice of asanas during an attack is different from when the patient is free of symptoms. If the patient is stable, standing poses can be practiced. Back bends are very helpful to open the frontal lungs and relax the bronchial muscle. Props may be needed. Immediate improvement in oxygenation occurs. The cells lining the bronchial tree are soothed by the improved blood flow and breathing mechanics of back bends. The sympathetic system being stimulated, the bronchi dilate. Constrictive activity is reduced with the lowered parasympathetic tone. During acute attacks such poses cannot be done by some patients. For such people forward bends are helpful. Forward bends are useful during an attack, but the requirement varies from person to person. The posterior lungs are made to open out or supported and rested, the secretions squeezed out and the nervous tone altered, relieving the stress on the lungs. Inverted poses condition the lungs for exertion of a particular kind. They flush the lungs free of accumulated toxins and enhance fresh blood flow, healing the irritated areas. The circulation of the bronchial tree has to be soothed and refreshed to prevent an allergic response. Props are usually needed. Sometimes no asana can be done-this must be recognized. At such times medication is the only life saver.

Role of pranayama Unless atmospheric pollution is drastically reduced, asthmatics will continue to find the going tough. Yet, one has to make an effort to control the disease. Pranayama is of direct help in this situation. The sympathetic tone is raised and vagal tone lessened; in other words, a balance is obtained. The effect can be felt soon after the practice of pranayama is over. A single long inhalation has been shown to enhance airways relaxation. The resistance to air flow in asthma occurs in medium sized airways. The slower and longer the inhalation, the better is the relaxation. The exhalation in yoga is never forced as it would narrow the bronchi. It is rather a slow, very deliberate process. It can take as much as one minute to complete an inhalation and exhalation (one cycle of breathing). The normal respiratory rate is 16 to 17 per minute. During pranayama practice it reduces to one or

two per minute. You can well imagine the relaxation of the bronchial tree. Regular practice improves ventilation, better control of smooth muscle as the process of breathing helps in voluntary opening of airways. There is a gradual change in the frequency of attacks and then a reduction in their severity. The breathing soothes the lining of the bronchial tree and prevents hypersensitivity to external allergens. Hence the chemical irritation of the lining is less. In pranayama, the varying rates of inhalation and exhalation give added benefits. As pranayama works at the microcellular level, stabilization occurs over a prolonged period of time. All asthmatics cannot start practice with pranayama. When they are breathless most of the time, how can they practice pranayama which demands slow breathing? First, the lungs need to be rested before breathing is done. Some need to practice asanas to stabilize the lungs and relieve the strain, before pranayama practice can be initiated. Pranayama is done lying down on pillows to promote deep breathing. Simple Ujjayi breathing may be used at first; and, as the condition improves, strenuous pranayama techniques can be taught which have better effects. If pranayama is practiced regularly the patient will most certainly feel a marked difference. Nevertheless, spasms may continue to occur and the patient should never stop practice in despair but persevere. Drugs may still be needed, but the patient will do better with yoga and medication than with medication alone. In some cases, yoga alone will suffice. As the disorder is one of a hypersensitive nature, relapses are common. Yet, in the long run, stabilization does occur. Many so called yoga camps conducted for asthma wrongly claim relief or cures in a short period. Asthma, being a chronic disorder, requires many years for stabilization, not to speak of a total cure. Resting poses like Supta Virasana, Setu Bandha Sarvangasana, half Halasana, Viparita Karani and Viparita Dandasana are some of the asanas recommended in the treatment of asthma. During an attack, the use of back or forward bends depends on the patient’s needs. All the asanas are done on props to help avoid strain and not provoke wheezing. As the condition improves, props can be dispensed with.

Chronic bronchitis and Emphysema Chronic bronchitis is a condition where there is excessive mucus production in the airways for at least three months in a year. This can be with or without pus in the sputum. Associated wheezing is well known. Emphysema is defined as distension of the air spaces distal to the terminal bronchiole, with destruction of the alveolar septae (Fig. 161).

Fig. 161 Lungs affected by emphysema.

In chronic bronchitis, there is increase in the size and number of mucus-secreting glands. In emphysema, the cells of the lungs are permanently destroyed.

Causative factors Again, for both the diseases, the causative factors are smoking, air pollution, occupational hazards, infection, etc. In emphysema, a deficiency of an enzyme inhibitor causes alveoli to be destroyed by certain other enzymes. Lack of this inhibitor can be a genetic predisposition. On the functional level, there is airways obstruction in both the diseases. In emphysema, there is loss of elastic recoil of the airways and the cells of the lungs. As the alveoli are inelastic and overstretched, drawn in air is not easily pushed out, resulting in air being trapped in the lungs. This makes the patient gasp as the lungs are over-distended. Poor oxygen exchange and expulsion of carbon dioxide, poor circulation of blood, and stagnation of secretions leading to easy infection, occur. The heart is constantly strained as breathing is labored. In the bronchitic patient, there is carbon dioxide trapping, with the patient becoming markedly blue in some cases; respiratory failure can result. The heart is overloaded, leading to cardiac failure. In contrast, patients with emphysema manage to maintain the carbon dioxide and oxygen levels in balance fairly well.

Symptoms

Bronchitis There is a history of recurrent muco-purulent cough with expectoration. This is often of long duration. Cardiac strain is more in this ailment. The back pressure creates cardiac or, more often, cardiorespiratory failure. Due to mucus plugging, it is more difficult for the blood to flow into the lungs; and the right ventricle finds it increasingly difficult over the years to pump blood. Carbon dioxide levels are high. Pulmonary hypertension is the result. Emphysema Breathlessness (dyspnea) is the cardinal factor. This is associated with varying degrees of wheezing and cough. Chronic hyperventilation and exertion of breathing keep the chest constantly elevated, giving the appearance of a puffed-up chest. The increased effort in breathing is due to deficient elastic recoil of the lungs which retain air and become over-distended. The diaphragm is always forced to the lowest possible position. The constant struggle often tires the patient. The accessory muscles of respiration in the neck are prominent.

Medical management The principles of management in both the disorders are somewhat similar. Oxygen is of prime value in both. In emphysema, it is beneficial for the patient to use oxygen for at least ten hours daily, especially in advanced cases. This helps to maintain the saturation of oxygen at near normal levels. In bronchitis, the infection should be treated with antibiotics, and oxygen if necessary. The emphasis here should be on preventing episodes of infections. In both disorders bronchodilators are useful to open the airways and push out the secretions. Sputum liquefiers are valuable to help expectorate. The goal in treating both the diseases is to maintain near normal respiratory function to help the patient carry on with daily activities. The pollution in the atmosphere today makes life miserable for both types of patients.

Yogic management Antibiotics remove infection, bronchodilators dilate, but to maintain the health of the respiratory system after recovery or before unhealthiness sets in, exercise is the only valuable tool. Exercise is the only way to help improve the mechanical efficiency of the lungs. The usual repertoire of exercises is too strenuous for the lungs, especially in emphysema. Exercises that do not raise the respiratory rate and yet help excretion of the sputum, increase oxygen levels in the blood, increase the elastic recoil of the lungs, prevent recurrent infections, and aerate the whole lungs, invigorating the patient at the end of the session, are necessary. Yoga stands out as the only system eminently meeting all these requirements. Asanas are very valuable in treating both disorders. Props are needed to prevent breathlessness as the lungs are already unhealthy, particularly for the patient with emphysema. Inversions on ropes are useful in promoting better drainage from the basal parts of the lungs. The steady pressure of the abdominal organs on the diaphragm develops endurance. The use of ropes prevents pressure on the lungs. As these disorders are worsened by clogging, poor clearance, fatigue of the lungs and spasms,

yoga works very well and it also works at the micro level, improving oxygenation to the cells. The principal point to remember is that while other exercises exhaust the lungs, yoga gives rest and rejuvenation. Asanas and pranayama work by gentle and steady methods, wafting the air into the lungs; other exercises are harsh and strenuous.

Purvottanasana on pillows rests lungs, relieves congestion.

Dog pose with rope rests the diaphragm.

Back bends help clear the bronchial tree of mucus by massaging the lungs. These poses give rest to the lungs and improve stamina. Effort tolerance improves. The heart and lungs are made strong in the bronchitic and emphysematic patient. The opening of the thoracic cage in back bends creates negative pressure in the lungs, allowing blood from the right ventricle to enter without strain. For the bronchitic, excellent oxygenation occurs. These poses are very valuable as they invigorate the lungs. In forward bends, the posterior lobes of the lungs are massaged and blood flow is improved. For emphysema, this position relieves constant strain on the heart. Twisting asanas squeeze the lateral parts of the lungs, improving their function. The asanas help better expulsion of trapped air in the emphysema patient. Resting poses such as Supta Virasana and Viparita Karani are very useful to remove strain on the heart and reduce the respiratory rate in the emphysematic pateint.

Head stand with rope. Inversions promote drainage from the lungs.

Shoulder stand on chair. The prop gives rest to the lungs which recover faster from breathlessness.

Urdhva Dhanurasana on ladder stool enhances the vital capacity of the lung.

Viparita Dandasana on chair with head rest, a more restful way of increasing lung capacity.

Standing poses improve the endurance of the patient in a manner similar to that of other exercises, but without the added strain. The vascularity of the lung, its mechanical components, its exchange capacity for gases, and the softness of the alveoli are preserved by the practice of asanas and pranayama. The drainage of mucus helps prevent recurrent infections. This benefit is of a significant nature for both conditions. Pranayama improves muco-ciliary clearance and stamina. The practice of kumbhaka facilitates better percolation of oxygen into the lungs and improves vital capacity. In the process of retention, the partial pressure of gases (in this case, oxygen) increases, which facilitates better and deeper entry as there is enough time for percolation. This improves O2 saturation of haemoglobin, thus enriching the quality of cellular food. This gives greater energy. To begin with, Ujjayi pranayama is introduced as it does not strain the lungs. Later, other varieties are more beneficial. A minimum time of 15 minutes of daily practice is essential. In emphysema, the need is to reduce the strain on the lungs by using a prop while practicing pranayama which allows more complete evacuation of the trapped air in the alveoli. With regular practice, the lungs empty and fill in a coordinated manner. The common medical instruction for patients with emphysema is to press the abdominal area to squeeze more air out of the lungs and through the mouth. This is a strain on the system. The dorsal spine must be supported by a prop. Only then must breathing begin. The accessory muscles of respiration in the neck are already strained in emphysema. Forcibly using them by pressing the diaphragm (which, in turn, tenses the neck muscles), must be avoided. Moreover, with the abdominal area compressed, the heart is also strained. If breathing is done fast there is also no time to prevent recurrent infections (by enhancing clearance mechanisms). The moment the patient lies down on the prop, the strain on the accessory muscles of respiration reduces. The benefits depend, of course, on how much of healthy lung tissue remains. All passive poses are good for emphysema. As the patient improves, active asanas can be practiced. In chronic bronchitis, both active and passive asanas can be done, depending on the condition of the patient. When the strain on the heart is relieved (by better pulmonary function), premature cardiac failure is avoided. The asanas are modified according to the condition and age of the patient.

Continuous follow-up is essential. The relevant asanas for all the above three conditions include Supta Virasana, Setu Bandha Sarvangasana on pillows, Dog pose with the rope, Purvottanasana on pillows, Head stand on the ropes, Viparita Dandasana on the rack, Urdhva Dhanurasana on the stool, Sarvangasana on the chair and Viparita Karani against the wall. All other asanas can be done as the condition improves. Pranayama is instituted when the frequency of attacks decreases, the spasms lessen, and the intercostal muscles function well. can only theorize that the increase in intra-abdominal pressure by specific asanas can enhance flow in the

Gastroenterologic Diseases Peptic ulcer This is probably the most common stress-induced disorder today. Anyone who is prone to tension is a potential patient. This disorder is an excellent example of how western medicine and yoga can work together. A good deal is known about its mechanisms and management.

Etiology Cells in the gastric lining secrete acid. Stimulation of the vagus nerve is responsible for acid flow. There is a chemical pump mechanism that causes acid release. Multiple factors influence this secretion: chemical, neural and mental. Gastrin, a regulatory peptide, stimulates acid flow. This is also present in the duodenal mucosa. Histamine is a chemical present in the gastric mucosa. This also stimulates acid flow by binding to H2 receptors. The protein content of food stimulates release of acid. Other substances like alcohol, non-steroidal anti-inflammatory drugs like aspirin, caffeine and oral calcium also stimulate acid flow. Inhibition of acid flow can occur by other chemicals present in the antral mucosa. Somatostatin is one such chemical. Fat in the duodenum also inhibits acid flow. Pepsinogen is an enzyme in the stomach responsible for the formation of pepsin. Both acid and pepsin can corrode the gastric mucosa. Secretion of mucus is a potent inhibitor of the corrosive effects along with bicarbonate ion secreted from the gastric mucosa. Once acid is secreted it cannot flow back into the cells as there is an effective barrier to this back flow. If this barrier is broken, cellular injury may result. Maintenance of normal mucosal blood flow is an important component of mucosal resistance to acid injury.

Gastric ulcer Age of occurrence is usually in the sixties, and usually ten years after duodenal ulcer. Gastric ulcer can be benign or malignant. About 55% of ulcers occur in males. However gastric ulcer is seen frequently in the younger group due to lifestyle alterations.

Causative factors Acid and pepsin are important in the pathogenesis. Some patients have duodenal ulcers in addition.

The exact mechanism is uncertain but damage to the mucosal lining occurs. Regurgitation of bile from the duodenum can be a factor in genesis. Helicobacter pylori (H.pylori) is found in a number of patients with gastric ulcer. This can cause recurrent ulcer formation and if let untreated cause gastric malignancy.

Symptoms The most characteristic is that of pain in the epigastric area (where the ribs diverge at the bottom of the sternum). The pain is precipitated by food. Other symptoms are nausea, vomiting, bloating and fullness after meals. The occurrence of gastric ulcer is less frequent than duodenal ulcer. Weight loss is common as many avoid eating because of the pain. Gastric ulcers can heal and recur in the same location, mostly in the antral region of the stomach. Hemorrhage is present in 25% of cases. If perforation of the stomach occurs, mortality is greater than for duodenal ulcers as the patients are older. There may be gastric outlet obstruction if the ulcer is in the pyloric area.

Diagnosis Endoscopy and barium meal are the two diagnostic methods. The latter gives an accuracy of almost 90%. Larger ulcers are often malignant (about 5%). A biopsy is needed to confirm malignancy. Endoscopic assessment allows cytological studies. H.pylori can be confirmed by tissue biopsy during endoscopy. Breath sensitive tests are also available. Medical management Antacids are the mainstay. Though acid hyper-secretion is not the feature of this disease, drugs like ranitidine, cimetidine and famotidine and newer acid inhibitors are useful in healing the ulcers as they inhibit acid secretion, allowing the area to heal. Side effects include rash, breast enlargement in males (gynaecomastia), reduction in sperm count, and impairment of mental status in elderly patients. However these drugs are usually well tolerated. The patient should follow a bland diet. Carbenoxelone, a drug from the liquorice plant, is effective in healing ulcers. It increases the life span of mucosal cells and the secretion and viscosity of mucus. Side effects include salt and water retention. Failure to heal in three months should suggest malignancy. Surgery is reserved for refractive medical therapy. With effective medical treatment this can be avoided. H.pylori infection is treated with a combination of antibiotics and the ulcer heals very well. Recurrence is common in developing countries due to unclean water and food.

Duodenal ulcer (DU) This is more classical and common. The ulcer penetrates deep into the mucosa. More than 95% occur in the first part of the duodenum. About 60% of ulcers recur within one year and 90% within two years.

Causative factors

H.pylori is a major causative factor. The number of acid-secreting cells is high, with greater outpouring of acid. Excessive acid flow is consequential, in comparison to gastric ulcer where defective mucosal resistance is the cause. Genetic factors appear to be important. Alcohol and cigarettes are potent causative and aggravating factors. Other causes include abuse of painkiller drugs, poor lifestyle, skipping meals (which allows acid to irritate the lining, the process being aggravated by stress on an empty stomach) and, most importantly, the mind. Stress produces and aggravates duodenal ulcer in any situation. Of this there is no doubt. All patients experience increase in pain with stress.

Symptoms The classic symptom is pain in the epigastric area present two to three hours after a meal. It is a burning, painful, gnawing or aching sensation, with fullness or bloating, even awakening the patient from sleep. It is relieved by intake of food or antacids. The severity of the pain varies, and recurrence is common with periods of remission. Any change in the pattern of the pain may herald complications-constant pain unrelieved by any agent may suggest perforation, or adherence to the pancreas behind it. Many patients with DU have no symptoms. There is often poor correlation between symptoms and healing. Surprisingly, duodenal ulcers never turn malignant. Complications are similar to gastric ulcer.

Diagnosis Pain in the epigastric region and a little to the right side and below it, if relieved by food or antacids, is in favor of DU. Double contrast barium and endoscopy is helpful in diagnosis. Small ulcers missed by barium can be picked up by endoscopy.

Medical management H.pylori eradication is essential. Healing of ulcers and relief of pain are the two objectives. Antacids like aluminium hydroxide and magnesium hydroxide are commonly used. The former produces constipation, and the latter diarrhoea in some patients. Antacids may be taken one hour after each meal and at bedtime. Acid inhibiting drugs are also used. They are taken with meals. Side effects are minimal, though they include rash, gynaecomastia, mental confusion and increasing the action of other drugs. Ranitidine, nizatidine and famotidine are effective. Omperazole is a well tolerated drug. Newer generation drugs like pantaprazole, lansaprazole and rabeprazole are very useful. Prostaglandins, which are chemicals present in the body, help ulcers. They reduce acid secretion, enhance mucosal resistance, stimulate blood flow, increase bicarbonate secretion and stimulate cellular regeneration. Other important measures include cessation of smoking and drinking, lifestyle changes to reduce stress (which is probably the most important) and avoidance of painkiller drugs. Within four to six weeks of therapy, most duodenal ulcers heal. If surgical procedures are undertaken for gastric ulcers, the area is resected and the remainder sutured. For duodenal ulcers, the duodenum is bypassed and the stomach joined with the small

intestine (gastrojejunostomy-GJ). There are many side effects: diarrhoea, (the vagus nerve is cut to reduce acid secretion and the vagus nerve controls gastric emptying), nausea, alteration in blood glucose due to the altered anatomy, and anemia due to malabsorption. The frequency of surgery for both conditions has decreased with advances in medicine.

Yogic management of peptic ulcer disease Yoga works along four principal mechanisms. First is that of intra-organ massage, improving blood flow and allowing better healing; second is by better glandular secretion of mucus; third is acid reduction by specific poses; and the last, and most important, control of the mind and senses. The quality of massage is such that in specific asanas like Supta Virasana, Purvottanasana and back bends done on props, blood circulates healthily in the gastric area. This helps healthy healing of ulcers and digestion which is hampered in such patients. Healthy absorption follows, with good energy levels. This reduces stress on the nerves. Each asana is held for a period of five minutes. Props are used, without which it is difficult to maintain timings. The stretch of the vagus nerve is probably the most important mechanism in back bends which reduces acid flow. Hunger decreases. The normal effect of stimulation of the nervous system and mind by back bends does not occur as the poses are done with props and with the bandage on the eyes. A particular property of an asana is nullified, yet the asana is used. Inversions promote a feeling of lightness in the organs at once. They also help good absorption of food and elimination of excess wind in the system. Forward bends, though they quiet the mind, are contraindicated, as they increase acidity with the vagus nerve being stimulated. They may be introduced after healing has occurred and the condition is under control with yoga alone. If drugs are still being used, forward bends should not be introduced. To relieve bloating, belching, fullness and acid burn after meals in both conditions, some asanas can be performed after food. These are Supta Virasana on pillows and Purvottanasana. They can be repeated any number of times in a day in addition to the morning and evening practice sessions. The effect is just like ingestion of antacids, and even faster as lightness is perceived in the organs at once. This feeling cannot be achieved by drugs. It is ideal to start treatment with drugs and simultaneously ensure asana practice (unless bleeding ulcers are diagnosed). The effect is additive. The drugs can be tapered off as the condition improves. Drugs work at the cellular level, inhibiting acid flow by antagonizing some receptors. Asanas work on the vagus nerve, reducing acid flow. This is healthier, especially in the long run. Yoga also quiets the entire system, inducing hibernation, so that all cellular responses are quietened. Drugs can be discontinued fully only after full healing of ulcers confirmed by endoscopy. Asanas maintain acid flow in old age, preventing invasion of the stomach by pathological organisms.

Supta Virasana is excellent for the treatment of non-ulcer dyspepsia.

It is also important for the person to make lifestyle changes by delegating work, practicing a little detachment emotionally from the work scenario, not being a perfectionist, adhering to meal timings strictly, and ensuring good sleeping hours. Keeping the mind in control is very important for patients with duodenal ulcer. The value of pranayama along with pratyahara has been repeatedly emphasized. The use of the bandage in asana practice cools the senses. Tranquility occurs, reducing acid flow further. This allows healing of ulcerated areas. Pranayama reduces sympathetic stress on the mind and the body, and thus acid flow is reduced. Again, the cells are not antagonized, it is along natural principles. Acid pain and other symptoms reduce very fast, if pranayama is done with total involvement and sense withdrawal. The contemplative type of Nadi Shodana is the best as it brings the mind to focus on the breath and produces withdrawal of the senses. The use of the bandage on the face is essential. The asanas useful for both gastric and duodenal ulcers include Supta Virasana, Purvottanasana, Setu Bandha Sarvangasana on pillows, Dog pose with the rope, inversions on the ropes, (which drain and allow fresh blood for healing the ulcerated areas), half Halasana (which removes stress on the mind), Setu Bandha Sarvangasana on the box and Viparita Karani. The gastric fire which is over stimulated is quietened by back bends. The question of how the same asanas work for both diseases may be raised. The reason is that, in both, healing is needed, acid flow is to be decreased, mucus secretion is necessary, and digestion is to be optimized. In the case of gastric ulcer, the stomach is kept comfortable after a full meal by these asanas. In the case of DU, the stomach and duodenum are kept non-irritated by the soothing of the vagus nerve. Non-infection acid peptic disease is a classic example of the breakdown of mind and body connections. It is interesting to note that persons who practice yoga from a young age never develop

peptic ulcer disease as the training of the mind and body is already instilled. Yoga philosophy teaches the right way to live, and asanas and pranayama protect the system. Even if there is mental stress, so long as the person is practicing yoga, the body does not feel the impact. It is easier to protect the body than the mind. Hence the ancients advised us to practice yoga so that at least the body is kept healthy and gradually, some day, the mind that is under stress can also be made likewise. Our ancient preceptors had no facility to measure acid flow in the stomach, no endoscopic facilities, no barium facility, and yet they analyzed the problem in their own way according to the theory that our body is made up of five elements, and the fire element is aggravated in such disorders. They even prescribed the correct asanas to alleviate them. How did they understand so much and even prescribe? Was it intuition? The silence that touches your mind when asked these questions will provide the right answer. For the relevant asanas refer previous section on respiratory disorders.

Metabolic Diseases Diabetes Mellitus Diabetes mellitus (DM) is the most common and possibly one of the oldest metabolic disorders in the world. It is characterized by multi-system dysfunction due to an elevated blood sugar level. Susruta has described this disorder in his medical text.

Pathogenesis and types of diabetes There are two broad types of diabetes mellitus: i. Primary or type I insulin dependent diabetes mellitus (IDDM), which develops before the age of forty. This is often seen in children too. It is almost certain that the disease is auto-immune in nature and that there is a genetic predisposition. The body’s defense mechanism attacks the pancreas and destroys the islets, and the level of endogenous insulin is very low. The situation is similar to rheumatoid arthritis. An environmental factor of viral etiology is also thought to play an important role in the genesis of the disease. The situation can be summarised as: genetic predisposition —> environmental insulitis —> activation of auto immunity —> destruction of the cells of the pancreas —> diabetes. ii. Type II non-insulin dependent diabetes mellitus (NIDDM), which is the most common form of the disease and accounts for 90% of all diabetics. This usually begins after middle age. There are three subtypes: non-obese, obese, and maturity-onset diabetes of the young (MODY). Endogenous insulin is adequate but, in the face of stress, may fail. The defect here can be either one of the beta cells failing to produce enough insulin or impaired tissue sensitivity to insulin. Secondary diabetes is caused by (i) pancreatic disease due to damage to cells of the gland; (ii) drugs like diuretics and steroids which can increase the blood sugar level; (iii) hormonal abnormalitiesover functioning of the pituitary and adrenal glands; (iv) insulin receptor abnormalities; and (v) genetic disorders. In IDDM, by the time diagnosis is made, 90% of the beta cells are destroyed. Progress has been made in the pathogenesis of NIDDM. In the earliest stages of NIDDM, the major defect involves the inability of insulin to promote glucose uptake and storage as glycogen. Other potential mechanisms to

explain the insulin resistance, include increased lipid oxidation, altered skeletal muscle capillary density/fiber type/blood flow, impaired insulin transport across the vascular endothelium, increased levels of amylin, calcitonin gene-related peptide levels, and glucose toxicity. No single mechanism may be operative in one individual. Symptoms The patient usually complains of passing a larger than normal volume of urine, with increasing frequency every day. The osmotic effect of increased levels of blood glucose causes more thirst and hunger. These classic symptoms, however, are not the normal presentation. Usually the disease is discovered on routine examination. Sometimes the patient suffers a frozen shoulder and this can be a manifestation of diabetes. Lethargy, weight loss and easy susceptibility to infections, particularly of the skin (like a simple boil or a fungal infection); excessive hunger, craving for sweets and sweating are some of the other symptoms. Diabetes may co-exist with other disease states. In this situation, it might be the diabetic condition that has made the patient prone to infection. Tuberculosis is the most common clinical condition which may also be present. Some others are malignancy, HIV infection, surgical stress, a heart attack, febrile illnesses and renal disease. Normally, the fasting level of blood glucose is less than 90 mg/dL and the post-prandial (2 hour) level is less than 120 mg/dL. If the post-prandial sugar level is between 150 and 200 mg, the condition is labeled as an impaired tolerance and, if above 200, it is frank diabetes.

Complications of diabetes Acute complications include ketoacidosis, a state of metabolic stress with overproduction of chemicals called ketone bodies. The patient suffers nausea, vomiting, dehydration and, if untreated, coma supervenes. This is always treated with insulin and replacement of electrolytes. The fluid deficit is around three to five liters. Any kind of stress-mental tension, a major infection or even a mere boil, fever, etc. can precipitate an acute increase in blood sugar level. Mental stress is the most common situation that raises blood sugar level. Stress drives the adrenal glands and this raises the blood sugar. Stress also prevents orderly secretion from the pancreas, which is unable to handle the extra load. Eventually, the majority of diabetic patients suffer long-term complications which can be prevented if adequate precautions are taken to stem the disease in the early stages by a healthy diet and, more importantly, by the inculcation of a daily exercise schedule. Long-term complications of diabetes Cardiovascular problems: The rate of progression of atherosclerosis is rapid due to the elevated blood sugar. Blockage of peripheral blood vessels creates intermittent claudication (pain when walking, the distance varies from patient to patient) in the legs. Silent heart attacks (due to narrowed coronary vessels) are the rule because of damage to the cardiac nerves that normally transmit the pain sensation of angina. Sudden rhythm changes in the electrical conduction of the nerves of the heart can

cause arrhythmias. These may manifest as a medical emergency with the heart coming to a total standstill. Sudden death due to autonomic cardiac dysfunction is well known. Hypotension and sudden fainting due to autonomic imbalance are also common. Eye complications: Diabetic retinopathy is one of the leading causes of blindness. The basic reason is hypoxia to the blood vessels which causes the various forms of retinopathy. The eye lesions are classified into background retinopathy and proliferative type. Because of hypoxia, there occurs increased capillary permeability, venous dilatation, leakage of protein and lipids, infarcts in the retina called ‘cotton wool spots’ (which are nothing but areas of dead tissue), bulging of the lining of blood vessels and hemorrhages. New vessels may form due to hypoxia. These new vessels affect vision and cause traction on the retina and subsequent retinal detachment. Photocoagulation is the treatment for neovascularization. Some loss of peripheral vision may occur. About 85% of patients develop eye complications. Diabetic nephropathy: Renal disease due to diabetes is a leading cause of mortality. The minute blood vessels undergo thickening and deposition of albumin and globulin material occurs. Atherosclerosis is rapid in the diabetic kidney. The cells of the kidneys shrink due to loss of blood supply, resulting in an ischemic shrunken kidney. There is loss of albumin in the urine to the extent of more than 30 mg to 300 mg per day. Recurrent kidney infections are also common. There is no specific therapy for diabetic renal disease. Renal transplantation offers a solution if renal failure occurs, but there may be other associated complications that may offer poor results. Associated hypertension has to be aggressively treated. Diabetic neuropathy: This affects every part of the nervous system with the exception of the brain. There is demyelination of the nerves due to ischemic changes in the minute blood vessels that supply the nerves (the vasa nervorum). Loss of nerve function causes symptoms like sensory and motor disturbances, severe pain, and altered sensation in the area of the nerve, the so-called diabetic polyneuropathy. The nerves innervating the joints are damaged. Pain in the joints due to wrong usage goes unnoticed as the nerves that transmit such pain to the cerebral cortex and spinal cord are damaged by excess blood sugar. This results in trauma to the joints, with the affected joints becoming deformed and ‘dead’. Sudden paralysis of any of the cranial nerves can occur. Spinal nerves are also affected, leading to pain in the muscle innervated (diabetic amyotrophy). Sometimes the affected area can also create a burning sensation. Gastro-intestinal complications: Autonomic dysfunction (imbalance between sympathetic and parasympathetic systems) affects the gastro-intestinal tract, resulting in delayed gastric emptying, constipation or diarrhea. The impaired colonic motility causes stagnation of bowel contents and colonization by pathogenic bacteria and infection. This diarrhea responds to the antibiotic tetracycline but the mechanism is ill understood. Bladder dysfunction or sexual impotence can occur. Skin disorders: Diabetic foot ulcers are a dreaded problem. The elevated blood sugar leads to

altered and defective protein synthesis and abnormal collagen formation, and the tissue formed is easily susceptible to trauma. Blockage to the minute blood vessels also causes ischemic necrosis of the skin and gangrene can result with added infection. This leads to easy breakdown of skin and formation of ulcers; and, since the nerves are damaged, the pain is not noticed even if there is gross infection. Healing of wounds is delayed due to poor circulation and low resistance of the tissues in a high sugar medium. The skin on the surface of the shin bone suffers specific lesions. The deposition of lipid-laden macrophages on the buttocks, back of the elbows and knees constitute what are known as xanthomas. What causes the complications? This is not known for sure. A substance sorbitol; a metabolite of glucose formed by activation of different chemical reactions, acts as a tissue toxin and is thought to be responsible for all lesions. A second mechanism is the formation of altered proteins in the body. The lipoproteins are also affected. Altered collagen traps this changed lipoprotein in the vessel walls. Thus blockage of vessels is accelerated. The lipid fractions in the blood are raised. Hyperviscosity, with abnormal aggregation of platelets also occurs.

Medical management Patient education is very important. Physicians must spend time to explain that this is a controllable situation and one need not despair. Patients too often do not comply. They abuse their diet and yet expect the blood sugar to remain under control. Firstly, a strict dietary regimen is very important. Secondly, exercise is very valuable. I am mentioning these before discussing the role of medication to emphasize their importance. A diabetic may manage without medication, but cannot manage without exercise and a healthy diet. Exercises like jogging and cycling increase the rate of entry of sugar into the cells and improve insulin sensitivity. As the cells are metabolically very active during exercise, they consume greater amounts of sugar and the blood levels of sugar reduce. The quantity and type of exercise needed varies from patient to patient and has to be monitored. Dietary modification depends upon the type of food the patient is exposed to; and the correct balance of proteins, fats and carbohydrate is to be taught. Generally, a low fat, high protein diet with normal carbohydrate intake is advised. If the patient does not exercise regularly, carbohydrate content is to be reduced. Protein is important unless renal disease is present. A young active diabetic needs around 1800 to 3000 kcal per day. The elderly diabetic needs around 1000 to 1800 kcal, and an obese middle-aged patient needs 1000 to 1600 kcal. In most diabetic diets, calories derived from carbohydrate are around 45% to 55%, from protein 15% to 20%, and from fat 30% to 35%. This is not a strict classification and there innumerable modifications possible from patient to patient. The intake of protein may be around 60 to 110 gm and that of fat is around 50 to 150 gm and of carbohydrate around 200 gm. For obese patients, reduction in weight is important as blood sugar level improves with loss of weight. Strict monitoring of this regimen is necessary. A measured diet is healthier than an unmeasured one. The role of fiber has already been discussed in the chapter on Health and Food. Fiber lowers the

absorption of sugar from the intestine and reduces postprandial increase in blood sugar. Beans, legumes, guar gum and bran help to control and reduce absorption of the LDL type of cholesterol. The Indian cluster bean is particularly valuable for its fiber content. Though artificial sweeteners can be used, they are better avoided as they are chemicals. Non-vegetarian food, with its high fat content, is not recommended. Alcohol is strictly prohibited. The goal of therapy is to maintain blood glucose to as near normal as possible. This is associated with fewer complications in the long run. The danger of low blood sugar during therapy has to be carefully tackled. Self-monitoring of glucose is convenient though regular hospital check-ups are important. There are a variety of user-friendly gadgets for home monitoring. Periodic laboratory check-ups are essential for counter checks. The treatment of IDDM is primarily by insulin. There are several kinds of insulin-short-acting, ultra short, intermediate and long-acting-which are used as the situation warrants. For example, if the sugar has to be normalized very rapidly, short-acting types may be used. Insulin lowers sugar in all kinds of diabetes. This delivery should be similar to endogenous natural pancreatic insulin; but then, man can never duplicate nature. At best a mechanical pseudo-imitation can be manufactured. The release of insulin is influenced by the state of mind which, in turn, influences sleep and so many other mental and physiological factors which regulate insulin release which no machine can sense and adjust. The delivery of insulin can be by a syringe, by a jet injection or by portable infusion pumps. Treatment with insulin does have problems. Hypoglycaemia is the most common dysfunction. Each method of delivery has its inherent problems. For example, when portable infusion pumps are used, signs of infection must be carefully watched for. The areas where insulin has been injected can atrophy, causing skin problems. The body can develop allergy, resistance, antibodies to the insulin delivered; and increased dosage of insulin may be needed as the disease progresses. Insulin from human sources is less irritative to the body, less stimulative to antibody systems and is better tolerated than most other kinds. Drugs used to treat diabetes, like tolbutamide, glibenclamide, glipizide, glyburide, glicazide, etc (the sulphonylureas), lower blood glucose in patients capable of endogenous insulin production. These are indicated for type II diabetes and in non-pregnant adults and most types of secondary diabetes. They stimulate the islets to release insulin and possibly decrease insulin resistance. Side effects include hypoglycaemia, rash, nausea and an increased risk of cardiovascular mortality. Drugs are the first line method of treatment if the situation allows it. In the elderly, who cannot try other modalities of treatment, these are very helpful. Another group of new drugs-thioglitazone, rosiglitazone etc are very effective to control diabetes. The side effects include weight gain, peripheral edema etc. Even for the middle-aged with maturity onset diabetes, it might be easy to reduce the sugar levels with a drug or insulin and then switch over to, or add, the component of exercise. In the long run, unless the tool of exercise is introduced, metabolic control is not satisfactory in all the types of diabetes. Role of exercise

The effect of exercise in IDDM and NIDDM stems from the fact that exercising muscles increase their uptake of glucose 10 to 20 times, depending upon the duration and intensity. High intensity exercise reduces blood glucose and fatty acids are used for energy. Exercise training enhances the action of drugs and increases insulin sensitivity. If the patient is obese, the development of such sensitivity takes a longer time. Blood sugar must be fairly under control before exercises are begun. Vigorous exercise training helps normalize blood sugar, either alone or in combination with dietary modification and drugs. For type I diabetics, habitual exercise is important. This improves cardiac function and lowers excess lipids. Individual monitoring of the response to exercise is important. If exercise sessions are intense, it is advisable to decrease insulin dosage and raise carbohydrate content. If the patient has peripheral neuropathy, irritative exercises like jogging which can cause foot damage should be avoided as the patient cannot feel the pain due to the nerves being damaged by excess blood sugar. Heavy meals should be eaten one to two hours before strenuous physical activity. This avoids the coincidence of meal and insulin effect. If the patient has any other existing complications like retinopathy or renal disease, very strenuous exertion to prevent rise in systolic blood pressure which can damage the weakened arteries should be avoided.

Yogic management Yoga is ideally suited for both types of DM. In IDDM, asanas help prevent an increase in insulin requirement over the years. In NIDDM, asanas help normalize blood sugar due to the high intensity workout. Yogic exercises can either be high or low intensity, depending on the clinical condition. A young active diabetic can be made to practice very intense asanas in a dynamic manner, which will increase the cellular activity of the muscle which then uptakes more sugar. The advanced asanas require a lot of energy and this helps normalize blood sugar. But, if the person is obese, asana practice is difficult and it is easier to reduce weight by other means and then take up yoga. Yoga increases the practitioner’s sensitivity to body movements and cellular changes. There is no pounding, flogging or forcible action in asana practice. The action on the cells is gentle and soothing and relieves the modified pathology by better blood perfusion, thus healing the area. Depending on the need the asanas can be modified. In yoga, it is possible to create a selective uptake of sugar depending on the group worked. Other exercises increase the general sugar uptake by the cells. Yoga selects the cells to absorb sugar. This is due to the wide variety of the geometric shapes of the asanas. The intensity of workout is total or regional. The single advantage of the asana system is that the internal organs are directly affected by the geometric shape of the asana itself; in other exercises the results are indirect. The danger of hypoglycemia in yoga is not so much as in other exercises because of the conscious control over the cellular systems. The advantage in the asana system is that even an elderly diabetic can practice it without any danger. Other systems might aggravate autonomic neuropathy and sudden death is possible. The emphasis in yoga is on controlling the autonomic dysfunction by means of pranayama. A prolonged observational follow-up of practitioners of yoga has shown that the incidence of DM is

very low. This is so only if yoga has been practiced from a very young age or very regularly. In fact, the incidence of most health disorders is very low in practitioners of yoga. The circulatory system, heart and lungs All the asanas are useful to prevent circulatory disease. Asanas impart strength to tissues, helping them resist cellular alteration in pathological states. Due to intra-arterial massage, the lining of the vessel wall is kept free of blocks (not in all cases). Moreover, the force of arterial flow can be increased and directed to any organ, which is of immense use in the diabetic state. In standing poses, the skeletal muscles increase their uptake of sugar. Hence, the tissues retain insulin sensitivity. Capillary changes are easily prevented by yoga as the action is on the vessel wall. Foot injuries are avoided because of neural and soft tissue massage and retention of healthy blood flow along with fresh oxygen which is vital to diabetic tissue. For the patient with a diabetic foot lesion in the early stages, asanas do not harm the sensitivity of the foot as the practice is slow and reflective. Injuries are less likely to occur in comparison with other systems. In very early cases, the situation of a diabetic foot can be reversed. Virasana is particularly useful for this purpose. Peripheral blockage of arteries never happens if the patient is regular in asana practice. Hence vascular disease, which is so common in diabetics, can be prevented by instituting yoga as soon as the diagnosis has been made. Of course, the damage may have already occurred; yet, more can be controlled after proper assessment of peripheral flow by investigational procedures. The use of the foot rest for improving blood in the calf muscle area is very important. This prevents neuritic pain in the extremities. Peripheral neuritis is prevented and benefited by standing poses. Back bends are very useful to fight blockage of coronary arteries. The maximum benefits are derived only with an early diagnosis and asana practice instituted as soon as possible, for atherosclerosis may have already progressed to a considerable extent. Angiographic evaluation of the quality of blood flow to the coronaries will provide baseline information of the status of the arteries. As the autonomic systems are balanced, irregularities in heart rate and rhythm are controlled. Hence the chances of a sudden collapse of a diabetic patient due to a cardiac lesion are much less. Asanas tone up the lungs also. Back bends, forward bends, standing poses, are all useful. Props may be needed for the elderly who have poor vital capacity. In this respect pranayama is highly useful. Oxygenation being better, tissue hypoxia never occurs. Digestive system Yoga is microcellular in its action. As the internal organs are massaged, sensitivity to insulin and uptake of sugar are enhanced. Gastric and intestinal activity is regulated and diarrhea or constipation due to autonomic malfunction does not occur. As the villi are massaged, absorption is better and sugar uptake is regulated. Twisting poses squeeze and massage the intestines. Hence, stagnation of colonic contents due to autonomic dysfunction cannot occur. At this point in time there is no evidence that any asana promotes insulin release-we can only theorize that the increase in intra-abdominal pressure by

specific asanas can enhance flow in the abdominal aorta and indirectly help pancreatic longevity. Backward bends, being very strenuous, help reduce blood sugar due to the intense work out given; yet in a different manner than that of aerobic exercises. Back bends improve blood supply to all abdominal and pelvic organs. This ensures healthy cellular integrity and due to the massage no deposits are formed. Forward bends increase the gastric fire and help healthy digestion of food. This prevents fluctuations of sugar levels in a diabetic. Hypoglycemic reactions are suppressed. Burning up of excess sugar is promoted by the stimulation of gastric fire. Renal system In renal disease, the increased systolic pressure in the renal artery and the protein load during aerobic exercises might further damage the kidney. Yoga makes arterial flow easier without an increase in systolic pressure. In yoga it is possible to control the velocity of blood flow to internal organs; in other exercises there is no control over the exercise process once it has begun. In yoga there are asanas to shut off blood flow or promote flow without velocity if necessary. Intrarenal massage can forestall deposits in the microcellular areas that damage renal tissues. Back bends are valuable tools against progression of renal lesions. They squeeze the kidneys and prevent stagnation of circulation and deposition of material that blocks blood flow to the cells. Hence, organ atrophy is prevented. In the early stages of a renal lesion, asanas can be very helpful. Even after a renal transplant, practice of asanas is very important to promote fresh blood supply to the donor kidney. If a diabetic patient who has no evidence of nephropathy practices yoga, debilitating renal disease can be averted. Passive back bends improve blood flow in the renal artery without much increase in pressure, while active poses enhance pressure; thus both are needed. Nervous system and special senses Inverted asanas prevent blockage of cerebral arteries (provided the practice starts very early in life). It may be stated tentatively that they might prevent the development and progression of retinopathy by maintaining microcellular perfusion of blood and oxygen into the retina without rise in systolic pressure. This also prevents further complications as oxygen supply to the tissues is maintained and enhanced. Forward bends soothe the nerves of the eye. They are preparatory to inverted poses. The retinal vessels are gently massaged and strengthened by forward bends. Standing inverted poses, like Uttanasana with the head on the stool, dog pose, Prasarita Padottanasana and Viparita Karani, have to be done with a pressure bandage on the eyes. Half Halasana is valuable to rest the retina. If the retinopathy is very advanced, much relief cannot be obtained. Competent guidance is essential to learn yoga if the patient has eye lesions. If standing poses try to prevent peripheral neuropathy, back bends prevent central neuropathy; that is, afflictions of the autonomic plexuses and sympathetic and cranial nerves. If diabetic neuropathy exists (whether in the distal or proximal parts), practice of other exercises may be harmful. Any injury to the tissues may go unnoticed by the patient. But yoga is very gentle in its action and the patient can restrain the intensity to any level. This prevents overstretching and injury. Moreover, the movements

are very slow in comparison to other exercises. In an early diabetic state, asanas prevent damage to the nerves. All asanas should be practiced to prevent neuropathy. Standing poses, back and forward bends preserve the integrity of the spinal nerves and the plexuses. In a well established case of diabetic neuritis, it might be difficult to abolish the symptoms. This is why yoga should be started as soon as the diagnosis is made. Asanas prevent damage to the minute blood vessels which supply the nerves that normally get occluded due to the pathological state. As healthy microcirculation and massage are provided by asanas, formation of new nerve sheaths is of a healthy nature. Skin The skin is massaged and blood supply preserved. As fresh blood flows through, resistance to infections is built up. The skin does not become waxy and unhealthy as it normally would. Elasticity is retained. Certain specific diabetic skin lesions are prevented if regular yogic practice is resorted to. Standing poses, Virasana, Padmasana, Mula Bandhasana, inverted poses, are all helpful in preventing diabetic foot lesions.

Role of pranayama Pranayama is highly valuable for improving oxygen perfusion to the tissues. As it also removes stress on the system, progression of blockage is arrested. Oxygen delivery to the tissues is systematic and sure. Tissue hypoxia never occurs. Sympathetic and parasympathetic stabilization prevent autonomic dysfunction. Even in an established situation of imbalance, depending on the individual merits of the case, relief can be provided. Prevention, relief or arrest of many forms of autonomic dysfunction can occur through pranayama practice. It is very useful for all complications of the diabetic state, particularly cardiac autonomic dysfunction, retinopathy and peripheral arterial occlusive conditions. I have not given a list of asanas recommended in the treatment of diabetes mellitus as all the different kinds of asanas are to be practiced.

Neurological Diseases Ischemic Cerebro-vascular Disease (stroke) This is quite a complicated phrase for a clinical situation. This is one of the leading causes of death after heart disease. There are many causes for stroke of which the most common is reduced blood supply to the brain due to aging, with atherosclerotic obstruction to the blood vessel. When critical narrowing results, tissue death occurs (infarction) with its attendant signs and symptoms. The other causes are inflammation, embolism where a fragment of material occludes the blood vessels, developmental malformation, infection, etc. The embolus could be from the heart or an atheromatous plaque from a carotid vessel or thrombosis in situ. The latter is probably the most common cause for a stroke. The prolongation of reduced blood supply causes a ‘hole’ in that area of tissue referred to as a lacunar scar. The human brain consumes the highest amount of energy. If blood supply is reduced even for ten seconds, unconsciousness can result. Neuronal death occurs; the extent of recovery is uncertain and dependent on multiple factors like age, health status, smoking, drinking, etc.

Diagnosis and symptoms The abrupt mode of onset of a neurological deficit is usually stamped as being a stroke. The patient can unexpectedly swoon, be suddenly unable to speak, to move the tongue, have difficulty in swallowing (the last three may be due to affliction of the centers of the respective cranial nerves in the brain with motor paralysis of the nerves), or sudden paralysis or paresis (a lesser degree of impairment) of a side of the body may occur with or without sensory symptoms. One entire side of the body can become paralyzed. For e.g.—if the right side is affected, the speech centre on the left side of the brain, (which is the dominant side for right-handers) is also affected. Mentation may also be affected. In some cases, a minor cerebral bleed can occur, particularly if pre-existing hypertension is present. The muscle tone becomes spastic and movement is difficult. There are specific signs and symptoms depending on which area of the brain is affected: the anterior, middle or posterior cerebral artery or the vertebral or basilar artery. It is beyond the scope of this book to discuss each area but it is important to understand the basic clinical picture. In most situations, the internal capsule area supplied by many arteries is the most commonly affected. The middle cerebral artery is the one most usually damaged. Lesions in the carotid artery cause motor and sensory loss on the opposite side of the body as the right side of the brain controls the left side of the body and vice versa. Loss of speech (aphasia) can occur due to failure of proper input to the brain, despite the fact that the articulation mechanisms are spared.

Lesions in the vertebral and basilar artery territory generally cause sensory loss, double vision, hoarseness of voice, slurring of speech, hearing loss or vertigo. Bladder and bowel dysfunction can occur, with resulting incontinence. Other dysfunctions in a stroke include difficulty in writing and recognition of faces, inability to manipulate figures, amnesia, and cortical blindness. The last is a lesion in the occipital lobes when the nerve centers in the brain are affected; resulting in loss of vision though the retina and optic nerve are intact. Other manifestations include loss of coordinated inputs causing apraxia where the patient is unable to carry out well coordinated movements despite the fact that motor and sensory functions are not severely affected. This includes problems of idea formation (in part or whole), dressing oneself, or constructional problems: making designs, for instance, either spontaneously or by copying. Agnosia is a situation where the patient fails to recognize objects or their uses, though vision is intact. Sometimes a stroke is labeled as ‘stroke in evolution’, the last word characterizing the situation. The patient develops signs and symptoms gradually. A situation known as transient ischemic attacks (TIA) is often a precursor to a stroke. This consists of focal neurological signs and symptoms which are reversible over 24 hours. Hence it is known as reversible ischemic neurological deficit (RIND). The patient may, for example, suffer sudden loss of function of one arm only to recover the usage within a few hours. Others are loss of speech, dizziness, slurring speech and double vision, all of which clear within 24 hours. Once a patient has had an episode of TIA, all efforts should be made to prevent a stroke. A special problem in older people is a condition known as DCA (diffuse cerebral atherosclerosis), where the entire circulatory system of the brain is jeopardized. The neurons slowly die. The person suffers loss of memory, fails to recognize familiar persons, disorientation in space and time occurs, and there are sudden outbursts of emotional crying and laughter. In addition, there are signs of dementia and motor and sensory impairment with paresis of cranial nerves on both sides of the body. This condition is known as ‘pseudo bulbar palsy’ as it mimics a true bulbar palsy due to other causes (palsy = paralysis; bulb is the older name for the medulla oblongata and refers to involvement of nerves in that area). In pseudo bulbar palsy there is difficulty in chewing and swallowing, and in phonation, yet the same muscles work properly in yawning, laughing, crying, etc. In true bulbar palsy, once the 9th, 10th and 11th cranial nerves are affected, no further voluntary movement is possible, in contrast to the incongruity seen in pseudo palsy. A CT scan with a contrast dye used can identify the area and cause of a stroke. A MRI is very helpful in assessing the affected area within a few hours of injury. Cerebral angiography, with its sophisticated ancillaries, is valuable in certain conditions. Doppler imaging is also useful, to assess flow abnormalities. Lumbar puncture may be needed to rule out other causes like infection. Other laboratory tests include a chest X-ray and an ECG to evaluate cardiac status, blood counts, and blood chemistries to evaluate metabolic abnormalities.

Medical management There is no specific treatment or cure for a stroke. Excellent supportive measures are available to prevent morbidity and mortality, waiting in the meantime for nature to allow recovery. The damage to

the neurons is more or less permanent in the older age group. In the younger age group (45-55), recovery may be possible though it may take a couple of years for total normalization of motor functions. After the patient is admitted to the ward, apart from baseline investigations, supportive measures include a lifeline with fluids, care of the bowel and bladder, prevention of lung infections, proper nutrition with a Ryle’s tube, and specific management of any other situation that might arise. Aspirin has been shown to be useful in reducing the incidence of strokes (though avoided when a bleed occurs). If there is cerebral edema in the affected area, steroids are administered. Vitamins and other supplements are needed. Preventive measures such as administration of anti-ulcer medication to prevent stress-induced ulcers, and regulation of blood pressure are necessary. With good care most patients make an uneventful recovery. However, sometimes complications can occur: fever, dehydration (especially in the elderly), and elevation of blood sugar as a stress-induced phenomenon, fits, and a cerebral bleed. All these can be managed appropriately. As early as possible, rehabilitation measures should be instituted to help reduce circulatory stagnation due to prolonged bed rest. Intense physical therapy is very helpful. The patient should continue physical therapy for many months after discharge. The ultimate factor determining the entire outcome depends on whether the patient has had a healthy lifestyle (eschewing nicotine and alcohol) in the years preceding a stroke. Western medicine is extremely useful and, in fact, the only method to treat a stroke victim. However, it does not offer guidelines to prevent a stroke in normal persons. No doubt drugs like aspirin have been shown to be prophylactic to a certain extent, but it is ridiculous for healthy persons to consume a drug regularly just because it has certain preventive benefits. The word drug means a chemical to be used in states of ill health and not when healthy. If so used, it is no longer a drug but food. Surely aspirin cannot become food. Asanas maintain the necessary quantity of blood to the needed area. There is no doubt that a natural maintenance of perfusion with an optimum quantity of healthy blood which yoga achieves is far superior. It is better to try and prevent a stroke since the damage could be permanent. This is one of the situations where yoga has very certain solutions.

Prevention of a stroke with yoga The most common cause of a stroke is a circulatory disorder due to aging, decay and rotting of the inner wall of the blood vessel. Assuming that, apart from the blood vessels, all other systems are normal, efforts should be directed to prevent aging of the inner lining of the vessels. Yoga is primarily a circulatory science and hence it helps maintain excellent body perfusion in all areas throughout life. All asanas do this. The most useful asanas to prevent a stroke are the inversions: Head stand and Shoulder stand. Head stand is the single most beneficial asana that can prevent a stroke. Cerebral perfusion is optimally maintained in those regularly practicing inversions. Healthy flow of pure blood prevents aging of cells. The oxygen content is preserved. Regular practice of this asana is a definite protection against a vascular stroke or an embolus or a breakage of a vessel, as elasticity of the blood vessels is maintained. Proper timing, a minimum of five minutes, is essential. The human brain is built to

accommodate only a fixed amount of blood flow. Inversions try to increase flow to the brain and the cerebral circulation resists the increase. Hence inversions are a challenge to the brain and it is this challenge to the constricting capacity of the cerebral arteries that serves to exercise the endothelial lining of these vessels. Hence the cerebral circulation is preserved as one ages. The question often asked of me is whether the practice of inversions can be commenced after middle age, or at a later age of 65 or 70. There is no age bar to practicing inversions. The body can be conditioned in any manner we want. Proper methods are needed, with intelligent understanding. For an aged person, obviously, yoga has to begin with simple asanas. Before inversions are practiced, training in forward bends and supported standing poses is needed. The latter improve coordination, strength, balance and endurance, lost because of the stroke. Supported forward bends restore the elasticity of the cerebral blood vessels which have become rigid after a stroke (see illustration in section on migraine). In any case, props are very helpful in providing timing and precision. After half Halasana is achieved without strain, inversions can be practiced. Even if Head stand cannot be done with props, Uttanasana on the stool (see illustration in section on migraine), Dog pose on the ropes, Prasarita Padottanasana on the stool, will all adequately improve cerebral blood flow. A bandage may be needed in individual cases. It is an interesting fact that the dowager Queen Elizabeth of Belgium learnt Head stand at the advanced age of 84 under Mr.Iyengar’s tutelage. As soon as the patient is discharged from the hospital, depending on the individual case, yoga can be instituted. Full protection from a repeat stroke is provided only after inversions are practiced for a period of three months. Regularity of practice is a must as inversions are ‘food’ for the brain. In forward bends the flow to the brain is made easy and is of a gentle quality. Back bends provide circulatory enhancement similar to endurance exercises but the force is controlled. Passive back bends try to provide gentle increase in cerebral flow as in inversions (e.g., Viparita Dandasana on the rack).For cerebral arterial flow patterns see my other book Yoga and Medical Science: FAQ where actual recordings of blood flow patterns clarify matters and remove myths on the properties of yoga poses.

Head stand is the single most important asana to prevent a stroke.

The relevant asanas to prevent a stroke include Dog pose with rope, Uttanasana with head resting on a stool, Prasarita Padottanasana, Parsva Uttanasana, forward bends, Head stand and Shoulder stand, passive back bends and Viparita Karani. For forward bends and Uttanasana refer section on migraine.

Migraine The term migraine (a French cognate to migranea) refers to periodic, hemi-cranial, throbbing headaches, often accompanied by nausea and vomiting. This condition usually begins in childhood, adolescence or early adult life and recurs in diminishing frequency and intensity as age advances. The female to male ratio is 3:1. Migraine has activators and deactivators. The former includes red wine, menses, hunger, sleep loss, glare, perfumes and depression, chocolate, cheese, tea, coffee, and antihypertensive drugs like reserpine. The latter includes sleep, pregnancy and exhilaration.

Causative factors There are plenty of theories. Migraine attacks are triggered by a variety of conditions including endogenous and exogenous factors. Evidence suggests that sensitization of primary afferent meningeal nociceptive neurons, the peripheral arm of the trigeminovascular system, constitutes one of the earliest events encouraging the intracranial pain of migraine. However, the link between the varied triggering factors and activation of meningeal neurons is not completely understood. There concepts include: 1) Vasomotor: During attacks cortical hypoperfusion has been demonstrated starting from the visual cortex and spreading at the rate of 2-3 mm/min. This hypoperfusion lasts 4-6 hours. The sub-cortical structures do not suffer reduction in flow. The factors that elicit these changes are unknown. There is a theory that if neuronal depression in the brain is widespread, it might precede or produce the changes in vascular flow. Ultimately, the problem is undoubtedly one of altered haemodynamics and neuronal state. 2) Serotonergic: The dorsal raphe (part of a set of nuclei in the brain stem) produces serotonin for the rest of the brain. Platelet levels of serotonin are low in migraine patients at the time of an attack. Serotonin agonists have provided relief (sumatriptan). This drug acts on receptors in cranial and basilar arteries and activation of these receptors causes constriction of the vasodilated vessels relieving headache. These nuclei stop firing in sleep and sleep is known to relieve migraine. The projection of these nuclei on the cerebral arteries alters blood flow. 3) Trigemnial–Vascular system: Stimulation of the cells of the trigeminal nucleus caudalis in the medulla releases vaso-active neuro-peptides that act on the vascular terminations of the trigeminal nerve and cause pain. The reason for the susceptibility to the stimulus is unknown.

Symptoms There are several sub types: 1) Common migraine: characterized by benign periodic headache of several hours (tension headache). This is the most frequent type of migraine. 2) Classic migraine: includes visual auras, vomiting, scotomas (loss of vision – reversible), and hallucinations. 3) Basilar migraine: symptoms refer to disturbance in brain stem function-25 % have vertigo, speech disturbances, and diplopia. This can occur in children and adults over the age of fifty. Altered sensorium is common and full recovery is the rule. 4) Carotidynia: lower-half headache of facial migraine-most common in the 4th and 5th decades. This is manifested by jaw pain, neck pain, deep dull aching in nature. Attacks number several per week. Headache and carotid artery tenderness is common. The headache of migraine may be in the front of the skull, or the sides, or the back, or a combination

of all. The pain may or may not be heralded by warning signs like visual scintillations, dazzling zigzag lines, photophobia (sensitivity to light), and dizziness. Other complications may be numbness of lips, transient paralysis of the arms or legs. Occasionally, partial loss of vision or cranial nerve palsies can occur. Cluster headache, whose incidence is higher in men, is characterized by pain in the eye, lacrimation, and rhinorrhoea. Migraine may recur after years of symptom-free periods. The situation is more often than not seen in perpetual worriers who are prone to emotional tension. Internal and external stresses are known aggravating and precipitating factors. Hence, this is partly a personality disorder. Reduction of mental stress is accompanied by a definite reduction in the frequency and severity of attacks. Yoga has said ages ago (I am particular about emphasizing this for the simple reason that, without any medical gadget in those times, the yogis have scientifically analysed the disorder) that a migraine headache is always neuro-circulatory in origin. Yogic theory also propounds that this disorder occurs only in persons whose minds are restless all the time. Once the mind which controls the senses and organs of perception is kept calm, headaches seldom occur. Unfortunately, in medicine, the factor of the mind is not given enough importance. Most of these headaches are due to some form of tension, and once the sympathetic tone is kept under control headaches are abolished.

Medical management Drugs are very necessary for acute pain. The side effects vary with the drug used. Beta blockers which work by inhibiting the sympathetic nerves are helpful in a proportion of patients. Ergotamine is a vasoconstrictive agent useful during the initial stages of the headache. Side effects include angina, peripheral vessel disease and headache. Dihydroergotamine is a useful alternative as it has fewer side effects. Repeated doses of analgesics only make the body respond poorly to them in the long run. Newer drugs like sumatriptan can be used under the tongue or as an injectable. This aborts the attack in a few minutes. Yet, the basic direction should be to stem the problem and not merely treat the effects. No doubt symptomatic relief is essential but if a problem is tackled at the root, relief is permanent.

Yogic management First of all, it is essential that the patient follows a healthy sleep-wake pattern. Preferably, one has to get to sleep around 9:30 pm and wake up around 5:30 am. Modification of lifestyle is essential. This in itself contributes to a certain amount of stress reduction. This alone will not abolish headaches though. A healthy diet is also important. In this respect, a flesh-based diet irritates the mind and should be avoided. Practice of pratyahara and dhyana are essential for introverting the senses and mind. This leads to a peaceful neuro-physiological state. With all these, unless asanas are practised, relief never ensues. Yoga works by improving the circulation and soothing the sympathetic nerves. As cerebral ischemia is one of the chaotic states in the problem of migraine, practice of Head stand abolishes this disordered state of flow. Regular practice of inverted poses maintains cerebral blood flow. In this

respect Head stand is the single most useful asana. Vasospasm does not occur in the arterioles due to the fact that the arterial tone is kept relaxed by relaxing the nerves which regulate the size of the vessel. The normal method of practice of inverted poses will provoke a headache for these patients as they are beginners in yoga and may induce tension in the irrelevant areas. Hence props are used. Prior to all this, practice of forward bends is essential. Once inversions are introduced, practice of forward bends before and after inversions is essential. All the poses are done with the eyes and ears closed by an elastic bandage. This relaxes the facial muscles. When the facial muscles relax they loose their grip over the organs of perception, thus relaxing the senses. Exhaustion of the sympathetic nerves is nullified. The ocular muscles are kept passive by a bandage. If the eyelids are constantly flickering when the eyes are closed, it means that there is tension in the brain. As the eyes sink into the sockets, the mind and the sympathetic nerves relax. Any manipulation of the tissues of the eyes has a reflex effect on the sympathetic nerves. In this respect, half Halasana is very useful as the tension in the sympathetic nerves is reduced. The frontal brain and the eyeballs are relaxed. Pain occurring at the back of the skull is relieved by this pose. The cervical nerves are soothed.

Janu Sirsasana (above) and Paschimottanasana (below), both with pillow. Forward bends decompress the facial muscles and the cranial cavity, relieving headaches. For beginners, practice of forward bends is essential before moving on to head stand.

Cross-legged forward bend with pillow. Where the classical forward bend is difficult for a patient, the cross-legged position is sufficient.

Forward bends are essential for migraine headaches. Without these poses, the disorder can never be abolished. Even if the classical variety is difficult for the stiff patient, bending forward in a simple cross-legged position is sufficient. The head should rest on a pillow kept at the level to which the patient can bend forward. The forehead is rested on the support (illustration on left). The effect of freshness and a soothing sensation can often be perceived at once. These poses soothe the eyes and the frontal brain, and rest is given to the sympathetic system. A kind of ‘decompression’ of the mind and brain occurs in forward bends, thus relieving frontal headaches. In forward bends there occurs a controlled flow of blood to the brain which is useful in the rebound phase of migraine when sometimes there is excess blood flow. Viparita Karani relaxes the nervous system excellently. The blood flow to the brain is kept up. As the nerves are profoundly relaxed in this asana, the system refreshes itself.

Uttanasana with head on stool regularises cerebral flow. To relax the facial muscles, the eyes and ears are covered with an elastic bandage.

A weight kept on the skull in this pose during a headache relieves the pain and makes it more bearable for the patient. The rationale of practicing forward bends before, and after, inversions is as follows: the forward bends soothe the nervous system and gradually push the blood flow to the brain; inversions are a step higher; and then, in order to gently bring back the state of normal blood flow, forward bends are needed. If this sequence is not followed, the headaches can increase; if strictly observed, liberation from the problem occurs. Savasana at the end of the sequence is essential to recover from the practice. The geometric shape of asanas quiets the mind and the brain. The membrane potential of a relaxed nerve is more stable. The sensitivity of the nervous system is altered and balanced in yoga. No other exercise works at the cellular level in the manner in which yoga does. Yoga is a system of biofeedback. Today this word is very much in vogue, but yoga has always stated that the brain and its chemicals have to be kept in a state of balance. The practice of asanas is different when the headaches occur. Regular conditioning of the nervous system reduces the incidence and severity of the attacks. The asanas are a form of conscious sleep and, like sleep, give rest to the mind and brain. Asanas sometimes reduce headaches even when sleep does not.

Some women suffer from migraine headaches during the menstrual cycle. This is due to neurohormonal changes. The practice of forward bends during periods is the usual recommendation for the reason that the nervous system is under stress at this time. Pranayama is highly useful to relieve the condition. Supine pranayama with pillows and bandage is the method. To begin with, Ujjayi pranayama is introduced. Later, as the nerves become stronger, Nadi Shodana pranayama is practiced. As this is the most introspective type of pranayama, the person has to transcend the senses and retreat deep within to listen to the controlled breath. The mind is silenced and headaches are relieved. If headaches are due to overheating of the system, Sitali pranayama is useful. Yoga states that a balanced activity of the ida and pingala nerves is important. In a migraine patient this is in a state of imbalance, which pranayama serves to regularize. Recall that ida cools the system and pingala heats the same (parasympathetic and sympathetic nervous systems). Stabilization of the trigeminal-vascular component is done by pranayama preventing release of mediators that cause pain. There are some kinds of headaches that are relieved by back bends but this is not common. Patients have to practice asanas regularly twice a day. If regularity is missed, relief is difficult. All the asanas are, of course, modified to suit the patient, using essential props. Props produce best results as the patient might strain in the wrong manner and aggravate the problem in the initial stages. As flexibility improves and the sensitivity of the patient in executing the poses is refined, the patient can practice without props. Obese individuals find it very difficult to perform asanas even on the props. They may need a longer period to get relief. In a nutshell, yoga poses and pranayama prevent the neurocirculatory mechanism from turning chaotic and is a preventive and curative for migraine. Pranayama functions like wise. Bastrikha and Kapalabathi pranayama should be avoided till health is restored. If the asana is done improperly, the headache may be accentuated. One must be capable of differentiating the induced headache from the natural one. Proper timing is essential in all asanas, especially forward bends. A minimum of five minutes is needed to produce the necessary biochemical changes. Western medical texts label yoga as an adjunct to migraine therapy. This is erroneous-yoga can be a primary modality here except for acute pain. The asanas that are recommended for migraine include forward bends and their cycle, Setu Bandha Sarvangasana, Uttanasana with support, Adho Mukha Svanasana with ropes, Head stand on ropes, Shoulder stand, half Halasana and Viparita Karani.

Gynaecological Diseases Dysmenorrhoea Painful menstruation (dysmenorrhea) from which millions of women suffer, and which makes life miserable for them for a few days every month and affects their relationship with family members and colleagues, is a totally avoidable misery; and it can be avoided without resorting to medication. Yoga is the answer to the problem. Actually, menstruation is one of the miracles of nature, the perception of which has been clouded by all kinds of socio-psychological hang-ups. Menstrual flow occurs when the inner lining of the uterus, which is to receive and anchor the fertilized ovum, is shed every month (in the absence of pregnancy), degenerates and flows out of a woman’s system along with the blood which is shed when the tiny capillaries attached to the detached lining break. Then, even as the old lining is shed, a new lining begins to grow; soft and velvety, laced with hundreds of tiny blood vessels, in readiness to receive a fertilized egg. Unfortunately, for many women, this normal and essential process is painful physically and, more so, psychologically. Stress plays a very big role in the menstrual cycle. Modern women are subject to the same kinds of stress—long working hours, unhealthy food, poor environmental conditions, emotional upheavals—that affect their male counterparts. Postponing the periods with hormonal pills is very unhealthy as the waste material meant for excretion is retained, damaging the lining of the uterus. If the woman’s lifestyle requires constant postponing of her cycles, it is a strain on the reproductive organs. All pre-modern civilizations—Greek, Roman, Hebrew and, also, Hindu—have treated the menstruating woman as ‘unclean’ and this prejudice colors our perception even today. Many women, because they have a hostile and resentful attitude towards menstruation, often magnify slight menstrual cramps into intolerable pain. However, sometimes the pain is real enough.

Causative factors There are three kinds of menstrual pain. The first type is ‘congestive’: pain occurs three to four days before the onset of menstruation, but is relieved by the onset of menstrual flow. There are many causes for this type of pain, but not all who suffer from it have an organic basis for the pain. Premenstrual tension is a good example of this. The real cause of this problem is imbalance between the sympathetic and parasympathetic nervous systems. Emotional tension often increases this type of pain. Stressful way of life, adulterated food, odd timings of travel and sleep, all upset this delicate mechanism. Congestive dysmenorrhea is usually a sign of myoma, or cysts of the ovaries, or alteration in the position of the uterus.

The second type of menstrual pain is ‘spasmodic’. In this, the pain develops on the first day of the period and may sometimes last for about 12 hours, the intensity of pain varying from patient to patient. The majority of the patients are in this group. There is accompanying nausea, vomiting and pain down the inner thighs. This problem usually reduces after a pregnancy. Menstrual irregularities may occur in this type of dysmenorrhea. Spasmodic dysmenorrhea may be due to altered polarity of movements between the cervix and uterus (normally, when one contracts, the other dilates). Or, the menstrual clot may be hard and improperly liquefied, causing pain. Probably the most plausible explanation is the fact that the uterus suffers from a severe cramp during the shut-off phase, when the blood flow is to be controlled. This cramp can cause considerable pain. Another theory is that the pain is due to a change in the structure of the uterus, which is rare. Other suppositions are hormonal imbalance and psychosomatic overlay. The most favored explanation is the action of prostaglandins that are present in all the organs of the body. They mediate a number of reactions in the body: constricting arterioles, releasing a hormone called renin, mimicking other hormones, increasing the permeability of blood vessels and so on. Prostaglandins can produce abortion or induce labor at term. They can cause severe constriction of the blood vessels of the uterus in addition to the muscle contraction of the uterine muscle. Excess constriction of blood vessels due to high levels of prostaglandins in a woman’s uterus can produce pain as it produces a state of ischemia. The third category of dysmenorrhea is ‘membranous’, which is an extreme form of the spasmodic type. This type is accompanied by the passage of membranous casts, which is extremely painful. Gastro-intestinal symptoms are also associated with menstruation, but this is only a functional problem due to associated autonomous imbalance. This is most amenable to yogic correction. Yet another type of dysmenorrhea is due to congestion in the ovaries; the nerves innervating the ovary malfunction, causing pain.

Medical management Anti-inflammatory and anti-spasmodic drugs are administered to treat menstrual pain are not to be abused. Inner organ dysfunction is evident in the long run, especially the gastric lining and kidney. The side effects outweigh the benefits. Hormones have a lot of side effects too, when used long term. Hormones work by inhibiting ovulation and the menstrual bleeding is non-ovulatory, and painless. There is, however, the potential danger of permanent suppression of ovulation. Surgical methods are not useful. The only procedure that might help is dilatation and curettage (D&C). This helps in some cases, but repeated procedures are to be avoided as the lining of the uterine canal might get eroded. Though it is replaced with healthy tissue later, it is not a sensible stimulus to the organ. Interruption of this situation with pregnancy relieves pain in many patients.

Yogic management Asanas regularize the blood supply and, at the same time, relieve congestion in the organ. The area with excess congestion bleeds more when the uterine mucosa starts shedding. In Baddha Konasana,

the uterus is given an upward lift, and Supta Baddha Konasana stretches the organ, so that congestion is removed; at the same time, blood flows only to the extent that is required. Due to this regularizing effect, excessive flow is relieved and, equally, in persons who have poor flow, it is enhanced. Due to the stretch of the organ, Baddha Konasana relieves abdominal cramps and low back pain during the cycles. Baddha Konasana is very beneficial for women who suffer from leucorrhoea. Upavishta Konasana with the spine erect provides excellent relief for dysmenorrheal low back pain.

Concave Uttanasana on horse, practised during periods, relieves back pain and abdominal cramps.

Supta Baddha Konasana stretches the uterus to remove congestion, thus relieving abdominal cramps.

In twists like Ardha Matsyendrasana, the blood is brought to focus into the right and left ovaries and uterus respectively. In properly done standing poses like Utthita Trikonasana, Parsvakonasana and Ardha Chandrasana, the uterus is lifted and stretched and excess bleeding is checked. Ardha Chandrasana cures abdominal cramps during the cycles. In back bends, the inward rolling of the knees with the stretch of the spine helps blood to be sucked into the uterus. Forward bends practiced during periods have a regulating effect on the quantity of menstrual flow, by creating a kind of physiological contraction in the uterus; thus, excessive contraction of the uterine muscle is prevented by the internal massage provided by the asana. Maha Mudra particularly supports the bleeding organ by elevating it. In Head stand and Shoulder stand, congestion and heaviness in the organ is removed. As the major causes of painful menstruation are ischemia and deficient polarity, asanas relieve the condition by changing the polarity, where one learns how to control the muscles of the uterus and cervix. By regular practice of inversions, excessive prostaglandins are removed from the uterus and are replaced with healthy fresh blood. This, in addition, prevents excessive contraction of the uterine muscle during menstruation. As the circulation is made dynamic every day, absence of chemical stagnation helps avoid excessive contraction of the uterine muscle. Ischemia does not occur.

Upavishta Konasana relieves dysmenorrhoeal low back pain.

Maha Mudra with rope supports the bleeding uterus by elevating it.

In conditions where the cycle is unaltered but the flow is prolonged, asanas can bring about the desired result when fibroids, polyps, cysts or retroversion are the causes. A malignant tumor obviously needs surgery. It is very useful to practice pranayama on pillows every day and even during menstruation. Stressful practice of pranayama is to be avoided during menstruation. Ujjayi pranayama is most useful at this time. The viloma variety, with prolonged exhalation and normal inhalation, is helpful in relaxing the sympathetic overdrive and altering the level of prostaglandins in the uterus. Over activity of the sympathetic nervous system is responsible for excessive activity of the uterine muscle and menstrual cramp. Pranayama practice with the elasto-crepe bandage removes sympathetic stress and relieves pain, as the senses are disconnected from the body. Nadi Shodana pranayama is very valuable for introverting the mind. This withdrawal from the external world soothes the irritative uterus. Asanas recommended for dysmenorrhea: Utthita and Parivrtta Trikonasana, Adho Mukha Svanasana, Head stand and its cycle, Shoulder stand and its cycle, Maha Mudra, Baddha Konasana, Supta Baddha Konasana and seated concave forward bends, Upavishta Konasana on a blanket, and Supta Virasana. After the condition ameliorates and the flexibility of the patient improves, back bends are introduced. If needed, the patient can practice back bends even in the initial stages with the use of props. The most useful of these is Viparita Dandasana with the chair.

Fibroids of the uterus Medically known as myomata, this afflicts 20% of all women over the age of 35. The incidence is far greater in women who have not borne children. It is of a benign nature and the most common of all pelvic tumors. It is not unusual to see women undergoing a hysterectomy for this problem, more often at a premature age.

Causative factors These fibroid tumors arise in the uterine muscle. They may either grow on the muscle or protrude into the lumen of the uterus. The exact etiology of myomata is uncertain, but it is thought to be estrogen dependent. Obesity (risk increases by 21% with each 10 kg of weight gain) and nulliparity are known risk factors. There is a risk reduction to one fifth with five term pregnancies, compared with nulliparous women. The combined oral contraceptive pill also reduces the risk of fibroids with increasing duration of use.

Shoulder stand on chair.

Head stand on ropes. These are most important as they drain the uterus (natural ischaemia) — and hence the fibroid — of blood, preventing further growth and inflammatory changes.

Fibroids can be single or multiple. They can be intra-uterine or extra-uterine. A variety of degenerative changes can occur with myomata which include calcification, fatty change, cystic degeneration, atrophy and malignant change. The last is very rare. Other complications include torsion and inflammation and, though a woman can go through pregnancy, yet myomata may interfere with the process. The growth is very slow and varies from patient to patient. African American women are particularly prone to fibroid development.

Supta Baddha Konasana relieves congestion in the fibroid by stretching the pelvic organs.

Baddha Konasana on pillow, erect.

Viparita Dandasana on chair. Back bends help to thin down the lining of the uterus and prevent tissue thickening.

Concave Uttanasana relieves back ache caused by fibroids.

Symptoms The most common symptoms are linked with the menstrual cycle. They are: (i) excessive flow due to the uterus (so that a greater area bleeds), because the surface of the myoma is highly vascular; (ii) reduction of the duration of the menstrual cycle with increased bleeding; (iii) vaginal discharge; (iv) inter-menstrual bleeding with dysmenorrhoea; (v) pressure symptoms on the alimentary tract, bladder, veins and lymphatics. Infertility may occur as a result of myomata. Most women are anxious about this condition and this increases the symptoms. Usually, if left alone, the condition ceases to trouble the patient, provided certain steps are taken in this regard. Stress reduction is most important. Most small myomata can be

ignored. Only if symptoms are severe, or if the size is greater than a 10 to 12 week pregnancy stage, does it warrant intervention. Medically, if the tumor is in the muscle or mucous lining and of a moderate size, it might need removal. After menopause, fibroids usually shrink and fibrose as estrogen levels reduce. Fibroids have been found in mummies and are hence referred to as ‘womb stones’.

Upavishta Konasana lifts the fibroid.

Marichyasana on floor with pillow squeezes the fibroid (ischaemia), preventing growth.

Medical management Treatment by surgery offers a cure for the problem; usually a total hysterectomy is done. Laparoscopic myomectomy (removal of the fibroid alone) maintains fertility compared to hysterectomy; reduces recovery time and postoperative pain compared with abdominal myomectomy. Laparoscopic vaginal hysterectomy reduces recovery time and postoperative pain compared with total abdominal hysterectomy, but increases operating time and blood loss compared with total vaginal hysterectomy. It is better if one of the ovaries is left behind, otherwise premature menopause results. But if ovarian pathology exists-a cyst for example, a progressive increase in size may occur. Hence, in some women, both ovaries are removed. Prompt calcium supplementation is essential to prevent osteoporosis. As an alternative to surgery, hormonal treatment to reduce pain and menstrual bleeding can be given to women anxious to retain their reproductive functions.

Yogic management

Hatha yoga tackles the problem in a different manner. It is important to institute the practice of yoga at the earliest opportunity possible. Usually the condition is diagnosed not as an emergency but on routine examination for a menstrual problem. An ultrasound reveals the presence of the tumor. Large tumors can be felt intra-vaginally. The best results of yogic management are obtained when the condition is diagnosed early and the size of the tumor is not excessive. A majority of women will do well on non-invasive management, provided the practice of asanas is regular. The asanas recommended for treatment of fibroids act as an irritative system, shutting off the blood supply to the fibroid for short periods while allowing blood to flow to other areas. Head stand and Shoulder stand are the most important since they drain the uterus of blood and, thus, ‘dry’ the fibroid which usually has a profuse blood supply. Regular practice of these poses will prevent excessive bleeding of the fibroid during the menstrual cycle. Once the stimulus of daily practice of inverted asanas is given to the organs, circulatory stagnation does not occur because of the flushing and drying effect. Circulation remains in a dynamic state. The vaso-constrictive mechanism of the bleeding vessels during menstruation is better owing to the relief given to the nerves. The cells lining the arteries also join together better in reducing the blood flow. Yoga regularizes the over-stimulated ovaries as the nervous and glandular systems are quietened. Supta Baddha Konasana and standing poses stretch the uterus and relieve the congestion in the fibroid. Menstrual pain and flow are thus corrected. There is an upward suction effect that happens in these asanas. One has to learn the technique. This prevents excess bleeding during the menstrual cycle. Twisting asanas squeeze the ovaries and the uterus daily, thus keeping a check on their hyperfunctioning nature. They cause a relative ischemia during the practice, and fresh blood irrigates the organs when the asana is completed. This action is essential to regulate the growth of a cell and its behavior. Thus, the size of the fibroid does not increase. After six months of these asanas, pain and menstrual flow will definitely decrease. If the patient perseveres in her practice, the effects are long lasting and surgery can be avoided. Women who perform asanas from a young age hardly develop fibroids. Surgery may be needed for some patients. Asanas recommended for fibroids are all standing poses, Head stand, Shoulder stand, Baddha Konasana, Upavishta Konasana, twisting poses and back bends.

Prolapse of the uterus Prolapse is the slipping or sinking of some bodily part or organ. This is a common complaint in which a part of the uterus abnormally protrudes into the vagina. The vagina also sinks downwards (this can happen without uterine prolapse, but the prolapse always carries the vaginal wall along with it). The uterus is held in place, with a certain amount of laxity and rigidity, by a number of ligaments. The looseness of attachment is essential as it permits changes in shape, size and position of the womb during pregnancy. It is also the reason why the uterus can be ‘tipped’ or prolapse occurs.

Causative factors The various causes of prolapse are: (i) rapid succession of pregnancies; (ii) application of forceps before full dilatation of the cervix; (iii) passage of large babies through the birth canal; (iv) obstetric injuries; (v) inadequate post-natal rehabilitation; and (vi) tumors, obesity and chronic bronchitis. Of all these, post-natal rehabilitation is something that should not be overlooked. To understand prolapse, the pelvic floor is the most important area to study. This area is constantly subjected to stress and strain when one sits, stands, walks, and during micturition and defecation. In many women the tone of the pelvic muscles is poor due to bad posture. This pressurizes the pelvic organs downward and outward. Unless this condition advances to a certain degree, no symptoms are felt. Recall the anatomy of the supports of the uterus: i. two broad ligaments attaching the uterus to the sides of the pelvis; ii. two round ligaments passing through the inguinal canal and merging with the labia majora; iii. two uterosacral ligaments attaching the organ to the sacrum; iv. two ligaments from the sides of the cervix; v. the tissues from either side of the bladder. All these supports are important for the uterus. Women who exercise regularly have better ligament tone. The muscles of the pelvic floor are used every day during defecation; if these are weak, prolapse is bound to occur. The muscles of the vagina used during intercourse have to necessarily be strong as lack of tone in these muscles indicates a higher chance of prolapse later in life.

Fig. 162 Stages of descent of prolapsed uterus.

There are several degrees of prolapse (fig 162): Stage 1: Slight descent of the uterus but the cervix remains inside the vagina. Stage 2: Uterus descends so that the cervix protrudes outside the vulva. Stage 3: The whole uterus lies outside the vulva. Normally, the uterus lies horizontally when the woman assumes an erect position, and there is no descent of either the uterus or the vaginal walls when she strains. In a prolapsed uterus, straining causes protrusion of the vaginal walls. In severe cases, the cervix is pushed down, and in extreme cases, the whole uterus could lie outside the vagina. The front or the rear portion of the wall of the vagina can prolapse. This could involve the urethra or the bladder as these are the structures in front of it which are carried down along with it. If the urethra is involved, the condition is known as an urethrocele. The urethro-vesical angle is altered (the angle refers to the position of the ligaments holding the urethra in place). If the bladder is involved, the patient may find it difficult to empty the urine. If the prolapse involves the back portion of the vagina, it may carry the upper part of the rectum or a few loops of intestine along with it. The prolapsed tissue can get ulcerated due to pressure and friction between the thighs.

Symptoms These are highly variable. Some women carry on for years with a major degree of prolapse; others complain of symptoms with a minor degree of prolapse. The symptoms include a sensation of fullness in the vagina, a dragging sensation (as though something weighty is pulled down), urinary problems, low backache, and discharge due to friction and ulceration. These are aggravated by coughing or straining. Symptoms are most noticeable after the patient has had a tiring day. Even in mild cases, the patient is conscious of a sense of weakness and a lack of support in the perineum. In most cases there

is some degree of vaginal discharge and imperfect control over urination, especially when the patient laughs or coughs. The incidence of prolapse of the uterus is higher in women of menopausal age who have borne children.

Medical management Prevention is better than cure. If good antenatal care and post-natal follow-up are observed this problem rarely happens. Rules of labor (like delivery being instituted only after full dilatation of the cervix and repairing any tear of the pelvic floor properly) go a long way in preventing prolapse. Surgical intervention is essential only if the symptoms interfere with normal activity. There are several types of surgery depending upon the nature of prolapse. Cystocele and urethrocele and prolapse of the rectum have specific procedures. The slack ligaments can also be cut and tightened. The results of an operation depend very much on the skill of the surgeon. Sometimes surgery can result in difficulty in intercourse and may interfere with pregnancy. It is possible to avoid surgery in many of the cases and take recourse to strengthening the pelvic floor muscles.

Yogic management If the prolapse is detected early, yoga provides complete correction. Unlike the usual repertoire of exercises prescribed, which only strengthen the voluntary muscles and do nothing to the inner supporting ligaments of the uterus, asanas directly affect the integrity of the supporting ligaments and strengthen them. The mechanics of asanas are quite different from the usual pelvic floor exercises. The most important of these is Supta Baddha Konasana with a belt. A woman can literally feel the uterus being pulled up in this pose. Both Head stand and Shoulder stand give immediate relief as the prolapsed organ is pulled back by the supporting ligaments. Head stand has to be done with the feet in Baddha and Upavishta Konasana. Parivrttaikapada Sirsasana is very beneficial.

Sirsasana

Sarvangasana Sirsasana and Sarvangasana on chair are crucial in repositioning the prolapsed uterus. Immediate relief results.

Supta Virasana pulls up the supports of the uterus.

Rotational movements in Sirsasana tone up the lateral (side) supports of the uterus. Shoulder stand variations are equally helpful, especially Setu Bandha Sarvangasana. Upavishta Konasana with a concave back creates space inside the pelvic floor and pulls up the uterus by means of its lateral and upper attachments.

Supta Baddha Konasana pulls up the lateral supports of the uterus, due to the pelvic floor opening laterally.

Viparita Dandasana on chair constitutes the most powerful upward pull for the uterus.

Standing poses like Utthita Trikonasana and Parsvakonasana hoist up the uterus by means of a direct upward pull. Back bends act by a suction force to pull up the uterus by contraction of the supporting ligaments. The contraction of the levator ani and the other pelvic muscles are at the maximum during the practice of back bends, the range of which is unavailable in other exercises. Seated twisting poses like Ardha Matsyendrasana and Marichyasana pull on the corners of the uterus. These poses are more beneficial if done with a concave back. Maha Mudra is very useful in toning up the uterine supports as the back is kept concave and this action pulls the uterus up. The uterus itself is not a fixed organ and has some intrinsic mobility. This should not become excessive, and regular practice of yoga prevents excess mobility. Coughing and straining increases intra-abdominal pressure. The pelvic organs get pushed downwards. In a healthy woman, the ligaments are strong and can resist this pressure. It is important to build up similar strength in a woman with a prolapsed uterus. As such pressures that can displace organs are nevertheless part of the body processes and the body is built to resist them, counter pressures and pulls to strengthen the supports of the uterus ligaments are used in asana practice. In a short period of two to three weeks, the patient will feel symptomatically better. All these asanas are valuable for associated prolapse of the urethra, bladder and rectum. Emptying of the bladder improves as soon as inverted poses are mastered. Stress incontinence has been dealt with in the chapter on pregnancy. Asanas like Baddha and Upavishta Konasana and Uttanasana with a concave back can be done even after a full meal. A short discussion must be included here about retroversion of the uterus. This occurs in 20% of women as a congenital problem. The patient may or may not be symptomatic. The decision whether or not to interfere surgically is the most challenging. Soon after childbirth the uterus may be retroverted. This often corrects itself as the muscle tone improves. The retroversion may be either fixed or mobile. The former is due to inflammatory lesions in the pelvis. The latter may lend itself to manual

correction; this is a delicate procedure. The symptoms of retroversion include congestive dysmenorrhea, excessive bleeding, excess mucus secretion due to congestion in the cervix and vagina, low back ache, and painful intercourse. Concave forward bends are very useful to lift and correct the retroverted position. Other forward bends are also valuable, where the convex forward poses push the organ forward. Inversions are helpful and the adjustments are delicately balanced. Back bends are not to be practiced as the retroversion will worsen. The perineal muscles are strengthened by yoga, as are the muscles of the vagina and cervix. Regular practice of Head stand and Shoulder stand keep the uterus toned up and firm. There is no contraindication to doing these poses even during pregnancy. Props are used if needed, especially for the elderly patient. Asanas recommended for prolapse of the uterus include Supta Virasana, Dog pose, all concave standing poses, Head stand and variations particularly Baddha Konasana, Shoulder stand and variations, Setu Bandha Sarvangasana, half Halasana, seated twisting poses like Marichyasana, Supta Baddha Konasana, Upavishta Konasana, Viparita Karani, and back bends.

ENT Diseases Vasomotor Rhinitis Millions suffer from this ailment which occurs in all parts of the world. It is disorder of the internal adjustment of the body to external stimuli. It makes life miserable for the sufferer, yet it is easy to control and abolish this problem. The lower three-quarters of the nose (that is, the part not primarily involved in olfaction) has the functions of heating and humidifying inspired air, and the trapping and destruction of inspired foreign particulate matter. It is an effective organ and, when a person is healthy, the air in the trachea is within one degree centigrade of body temperature and 90% humidified, irrespective of the atmospheric conditions. The blood supply to the nasal septum is by the branches of the external and internal carotid arteries. The anterior part of the nose near the tip, known as Little’s area, can bleed easily as the blood flow is plentiful. The amount of blood flow and, therefore, the degree of heating and the amount of mucus secretion and, therefore, the degree of humidification, are under autonomic nervous control. The parasympathetic component causes dilatation of the blood vessels and an increase in the amount of secretion and the sympathetic component causes constriction of the blood vessels and a decrease in secretion. These two systems are normally in balance and provide the correct degree of blood flow and mucus secretion to heat and humidify the inspired air, and to give a clear moist nasal airway. There are many normal reflexes associated with the nose. Most people with mild nasal obstruction will have noticed that their nasal passages, either on one or both sides, become more blocked when they retire at night, and that if they lie on one side, the nostril of that side becomes blocked. This is a normal physiological reflex. But, in sensitive persons, the lining discharges more mucus than normal. This physiological reflex may be exaggerated in some. Similarly, a change of temperature affects normal nasal conditions -a cold wind causing increased secretion and a hot humid stuffy atmosphere causing nasal obstruction. A large heavy meal, tobacco smoke, the ingestion of alcohol, cold damp feet, an overfull bladder cause nasal obstruction. These are all examples of normal vasomotor reflexes. Vasomotor rhinitis is the name given to the situation where the nasal reflexes are oversensitive. There is increased parasympathetic activity leading to dilatation of the vasculature within the inferior and middle turbinates, causing nasal obstruction; and increased mucus secretion causing rhinorrhoea and sneezing. These turbinates are plates of bones on the outer wall of the nose. Along this line are the

openings of the ducts of the sinuses. It is important to understand that very few human beings breathe through both nostrils in daily life. There is always a subtle reduction in flow on one side. If this is exaggerated, the blockage is very symptomatic. The sensitivity of the lining of the nasal passage to external temperature and other stimuli is never the same on both the sides.

Causative factors There are several etiological factors which are recognized as causing vasomotor rhinitis. Any of them can be present singly, or several may coexist in the same patient. The most common is psychological stress which is usually seen in adolescents, in women in their forties and in men in their sixties. The sufferers tend to be introspective and to react to conflict with feelings of frustration and depression. Change of climate is also important and vasomotor rhinitis is frequently encountered in immigrants from warmer countries. The symptoms are apparent within a few months of arrival. Endocrine conditions affect the nose. A very common physiological condition is pregnancy, particularly during the third trimester. Contraceptive pills, especially the high estrogen variety, cause similar symptoms. Myxedema can also be implicated. As vasomotor rhinitis is due to relative parasympathetic over activity, any sympatholytic (opposing sympathetic activity) drug will cause it. Beta blockers used in the treatment of hypertension and angina pectoris can cause blockage of the nostril. Psychotropic drugs, especially the phenothiazines, are other potent causes.

Symptoms The complaints include nasal blockage, watery discharge (rhinorrhoea) and sneezing. The symptoms are intermittent and last for several hours at a time. They are stimulated by changes in posture and temperature, and often trouble the patient on retiring to bed at night. They are again obvious first thing in the morning on rising, especially if the ambient temperature is low. There is profuse watery rhinorrhoea with sneezing, and constant blowing of the nose does nothing to relieve the obstruction. The sinus ostia (openings) become blocked by the general mucosal congestion, causing pressure changes within the sinuses, and leading to dull aches around the face. Examination of the nose reveals that the turbinates are enlarged, especially the front ends of the lower turbinates, with increased mucus production. The septum is of normal color which differentiates the clinical picture from that of an infective condition. Purulent crusts and sticky secretions are absent. Examination of the pharynx often shows pharyngitis with irritated or enlarged lateral pharyngeal tissue due to the post-nasal catarrh. A polyp is a tissue growth caused by a number of factors. Any chronic irritation to the nasal lining can produce a polyp. Vasomotor rhinitis does not lead to polyp formation. Radiography of the sinuses is unnecessary in coming to a diagnosis and, in fact, can often be misleading because, if the patient is in an active phase of the condition when the x-ray is taken, the increased vascularity of sinus mucosa will be revealed as mucosal thickening, which could raise the possibility of chronic sinus infection.

It is worth emphasizing that vasomotor rhinitis is a variation of the normal rather than a disease entity. Many of the sufferers who seek medical help are tense and unhappy, as no drug seems to help. It is a common problem and rather than blindly instigating medical or surgical treatment it is advisable, as a first step, to stress the normality of the nasal reflexes and their causes, so that the patient can learn to avoid stimulating them.

Medical management Decongestants are the mainstay of medical treatment. They can be administered either locally as drops or orally as tablets. Local decongestants must never be used for more than a month at a time, or they will lead to rhinitis medicamentosa (a condition where the nasal lining becomes accustomed to the effect of the drug and cannot manage without it even though the original pathology may have abated). If they are not effective within this period, continuation is not warranted. The best decongestants are oxymetazoline and xylometazoline, which cause the least rebound reactive congestion in the lining of the nose when their effect ceases. Systemic decongestants such as pseudoephedrine can be used over a longer period of time, but have more side effects such as dryness of the mouth and constipation, and they are contraindicated for patients with glaucoma, hypertension and cardiovascular disease. In the rather disturbed patient, amitryptiline is a useful drug because, apart from improving the patient’s depression, it also has a fairly strong anticholinergic effect (decreasing the secretions).

Yogic management Yoga is the most effective form of treatment as it stabilizes the sympathetic and parasympathetic systems. As this occurs, the hypersensitivity of the nasal nerves is toned down and so are the symptoms. Secondly, as blood supply to the nasal mucosa is regulated by inverted poses, the sympathetic nervous system is refreshed and stabilized to overcome the parasympathetic tone. Standing asanas play a very important role in releasing endogenous steroids which serve to constrict the dilated vessels. Sarvangasana is the principal asana which effectively abolishes rhinitis. Half Halasana quiets the nasal nerves by decreasing the parasympathetic tone and re-energizing the sympathetic system.

Setubandha Sarvangasana, done at the time of congestion, causes drying of excessive nasal secretion.

Head stand. Blood supply to the nasal mucosa is regulated by inverted poses.

The combination of these two asanas abolishes symptoms and regularizes the nervous system. The disorder is one of the most common for which yoga finds a clinical application and is the easiest to treat. All other asanas may be practiced but Shoulder stand and Halasana are adequate. The patient should practice Sarvangasana and half Halasana late in the night before retiring and early in the morning, to control the problem. The late night practice stabilizes the nervous system during sleep. A minimum time of five to ten minutes in each asana is imperative for effective results. If, on arising in the morning, sneezing occurs, the asanas can be practiced and relief is immediately perceivable. This works faster than any drug and is devoid of side effects. Regular practice is essential. Later, as improvement occurs, Head stand can be practiced. With regular practice of inversions the patient can look forward to a trouble free life. In fact, when sneezing occurs, if the patient assumes half Halasana, the nasal lining tends to become soothed and dry. The watery discharge stops. Even if the patient has a strong allergy to smells and dust (which actually causes allergic rhinitis), asanas relieve the condition, making the system resist allergy better. Practice of pranayama is very important for vasomotor rhinitis. The effects of pranayama in stabilizing the autonomous nerves are invaluable, although it cannot be started until the nose is made

‘quiet’. Pranayama is possible only if the nose is really decongested. In this respect, digital pranayama is good. The varieties include Surya and Chandra Bedhana, Anuloma and Pratiloma and, finally, the king of all pranayamas, the Nadi Shodana. If the patient can develop sensitivity of the fingers and nasal lining to practice Nadi Shodana, it means that the cells of the nose have really quietened. Some of the asanas are illustrated.

Shoulder stand with blankets. Together with half halasana, this forms the most effective treatment for rhinitis, by inhibiting excessive nasal sensitivity.

Chronic Sinusitis Sinusitis is an endemic problem in many parts of the world. In India, for example, it is widespread in the colder parts. It can be a great irritation if you are susceptible to it, causing headaches and general discomfort. Pollution in cities is another main reason for constant irritation of the sinus. Occupational problems like exposure to certain chemicals or to fibrous material like wool and cotton can also cause such irritation. Smoking is a principal aggravating factor. Constant use of mosquito repellant vapors can cause allergic sinusitis. Close contact with house pets can perpetuate the condition of allergy.

Causative factors Inflammation and swelling of the mucous membranes lining the sinus cavities causes sinusitis. This, in turn, could be caused by infection or over stimulation of the mucous membranes of the sinuses by cold

air during the winter season, especially during sleep when metabolism is low. Smoking reduces the effectiveness of the nasal muco-ciliary clearance by damaging the lining of the sinus. Poor systemic as well as local immunity in the sinuses are predisposing factors. A common provocation is nasal allergy. A crooked nasal septum adds to the problem. An allergic tendency of the entire system (even if not just local) causes inflammation of the lining of the sinuses and subsequent infection. There is an anatomical predisposition for the maxillary sinuses to get clogged. This is due to the fact that their duct has an upward course to empty the secretions into the nose; the frontal sinuses have a downward course which is helped by gravity. Though the deeper placed sinuses, like the sphenoidal and ethmoidal ones, are not under strain in emptying their contents, they are susceptible to chronic mucoid infection. The sinuses empty their contents into the nose through a small opening in the nasal lining known as the meatus. The clearance problem is of a mechanical nature. The lining of the nasal cavity is highly vascular and temperature sensitive. It is innervated by both parts of the autonomous nervous system. Sometimes the frontal sinuses transmit their secretions into the maxillary.

Symptoms The common symptom is that of nasal blockage and muco-purulent discharge. This is worse early in the morning as the recumbent position drains the sinuses and, on waking up, the patient sucks the phlegm from the nose and expectorates it through the mouth. A sensation of discharge from the roof of the mouth into the throat is also common—the so-called post nasal drip (PND). This can track down into the lungs and produce a lower respiratory infection. In acute infectious conditions there is pain over the affected area, fever, reddening of the overlying skin and a constant nasal discharge. After recovery, the disease can become a milder form of chronic mucus discharge which is aggravated by the ingestion of cold drinks, ice creams, etc. This is again followed by fever and another acute bout of sinusitis.

Medical management An x-ray, CT scan or endoscopy of the sinuses may reveal the extent of pathology. Sometimes there is an associated mucoid growth which may require surgical removal. In the case of sinusitis caused by infection, antibiotics are essential. A specific antibiotic is prescribed and the patient followed up for a few weeks to ensure clinical resolution. Frequent topical applications of medicine or using the inhaler to decongest the nasal lining too often may, in fact, further irritate the mucous membrane, causing rhinitis medicamentosa. An acute attack of sinusitis has to be necessarily treated with antibiotics and analgesics. Sinus cavity clearances, once undertaken, have to be repeated again and again because the anatomy of the natural clearance mechanism is destroyed. Once an episode of infection has been treated by antibiotics, the prescription should change. Inhalation of medicated steam (with tincture benzoin) is useful in decongesting the sinus lining. Surgery is not advisable in all cases for the mucous lining is never the same afterwards. Healthy regrowth of cilia to clear the sinuses is difficult after surgery. Many patients suffer recurrent watery discharge for many months after surgery. A well-balanced diet and a good regimen of living help to build up resistance to the condition. The

lining of the nasal passage is very delicate and has cilia to trap dust and other foreign particles. If the blood supply in this area is poor, the circulation of T and B cells is hampered. Exercise helps increase the concentration of such cells. Strict avoidance of active as well as passive smoking is essential. Avoidance of soot and other pollutants, as far as practically possible, is needed. If there is an occupational hazard of exposure to substances that the patient is allergic to, a face mask is needed. Consider a change of job if the situation warrants. The patient should avoid the use of cotton pillows and bed sheets as allergy is a potent aggravating factor. This is regardless of whether the patient is susceptible to the particular allergen.

Yogic management Yoga works by promoting healthy drainage of secretions and boosting a flow of pure blood to the sinuses, thus flushing and removing stagnant blood. Fresh red blood corpuscles laden with oxygen and immune cells rejuvenate the lining of the sinus. All inverted asanas promote healthy drainage of the secretions so that stagnation does not occur. Thus, inflammation is prevented. Just as prolonged standing causes congestion in the legs, the sinuses too get congested in the erect posture. Inverted poses like Head stand; Sarvangasana and half Halasana help open the meatus through which the sinuses drain their secretions into the nose. Natural puncture thus occurs. In fact, the patient often perceives relief as the pose is being performed; particularly Shoulder stand and half Halasana. Soon after completing the pose, many patients spit out phlegm. This process continues for many days after which no further drainage occurs as the sinus cavities are empty. From this stage, regular practice of asanas keeps the cavities empty. Contrary to common thought that the sinuses could become congested when the body is inverted, they become very light and the spread of infection to the other sinuses is limited. There are many internal adjustments which prevent congestion when these asanas are done. As congestion is relieved, the headache resulting from chronic sinusitis is relieved. Regular practice of asanas thus keeps the nasal passages free. In addition, practice of pranayama relieves heaviness in the sinuses and collection of phlegm is reduced. Inversions are contraindicated during and acute attack of sinusitis. After relief and stablisation of the condition, these asanas can be practised.

Half Halasana on stool drains the sinuses of all secretions.

Head stand on forehead provides healthy fresh blood to congested areas, removing toxins.

Standing poses like Trikonasana clear the sinus very rapidly due to release of endogenous adrenaline and noradrenaline. Head stand and Shoulder stand are mandatory, along with forward bends. The practice of Sarvangasana and half Halasana on a rolled mat at night, before sleep, is essential. The positioning of the cervical spine on the rolled mat opens the nasal passages at once and congestion is relieved. This helps to keep the sinus comfortable during sleep. Nadi Shodana pranayama helps in excellent muco-ciliary clearance due to the steady flow of air in and out of the nasal passages. Fresh air aerates the stagnated sinus and creates changes in blood flow in the lining of the cavity, which also decongests the sinus. Due to rhythmic passage of air at a certain force, secondary changes in the nasal cavity, such as hypertrophy of the nasal turbinates or thickening of tissues due to chronic inflammation, do not occur. The sheer calculated pressure of the inflow and outflow of air prevents the thickening of tissues even after surgery by controlling excess growth. This is an example of scraping of body cells by the action of pranayama. A deviated nasal septum causes reduced ventilation on one side of the sinus. If the deviation is gross, surgery is essential. After two to three weeks, when the mucosa has healed, asanas and pranayama can be practiced; if not, the lining of the nose becomes thick, resulting in repeated obstruction.

As yoga teaches us the art of natural puncture, operations on the sinuses can definitely be avoided except for purulent sinusitis and growths. Regular practice is essential. Ages is no bar in practicing these asanas, nor are problems like cervical spondylitis, high blood pressure. The pregnant woman can safely continue her practice depending on certain conditions.

Shoulder stand on rolled mat. Positioning of the cervical spine on the rolled mat opens the nasal passages, causing ‘a natural puncture of the sinuses’.

Asanas recommended for sinusitis are all standing poses, Head stand on the forehead, Sarvangasana on a rolled mat, half Halasana, forward bends and back bends. Some of the relevant asanas are illustrated.

Orthopaedic Diseases Cervical Spondylitis A very common disorder, normally seen in the age of 55 onwards, cervical spondylitis today is increasingly frequent in the younger age group from 25 to 45 years of age. There are several reasons for this. Before reviewing the patho-physiology, let us understand the developmental concepts. This is a mechanical disorder. Apart from very stiff muscles in the cervical region which can cause a kinking of the cervical spine to the front (over the years), bad posture and lack of exercise to the cervical region are the key factors which are responsible in a majority of the patients. Reclining in bed with several pillows propping up the neck into an unnatural position can affect the alignment of the cervical column, causing a forward inclination. Lounging sofas with the spine hunched and the neck pushed forward harms cervical alignment. Occupational hazards affect computer professionals, authors, illustrators or a painter, where the spine is hunched all the time. Positioning the body to the same side during sleep, with the shoulder muscles and the neck compressed, also develops faulty alignment in the cervical spine. In due course the spine is bent, the front surface of the bones and disc are excessively pressurized and damage occurs. The so-called executive chairs are ill-designed and push the neck out of alignment. No chair should reach over the head. The level should be up to the shoulder blades so that the chest can stretch over the edge keeping the body upright. In India, railway porters carry heavy loads on their heads but they do not suffer from cervical pain (as one would expect) from the heavy load they carry every day. Only in the group of people who never exercise their bodies does this occur most frequently. Essentially, the pathology consists of: (i) narrowing of the cervical vertebrae with disc space reduction; (ii) friction between two vertebral bodies created by this narrowing, with an osteophyte (bony spur) forming (fig 163); (iii) loss of normal concavity in the cervical region, i.e., loss of lordosis; (iv) symptoms of vascular insufficiency; (v) numbness and tingling sensation in the hands or feet due to the compression of the cervical nerve roots. The problems of vascular insufficiency consist of vertigo, giddiness, occasional tinnitus (a ringing sensation in the inner ear), a sense of unsteadiness, etc. In a severe case, there is transient loss of consciousness. The vertebro-basilar vessels are important arteries coursing along the cervical column to the back of the brain (fig 164; see also figs 72 and 76 in section on cardiovascular system). There are areas here that serve balance and posture. If the blood flow is affected, the

corresponding function is also compromised. As the anatomical arrangement is intricate, any movement in the neck affects the flow of blood in the arteries. This syndrome is known as vertebrobasilar insufficiency (VBI).

Fig. 163 Spondylitis of the cervical spine. Simple degeneration and narrowing of the disc, with anterior formation of osteophytes (left), is followed by wearing away of the articular cartilage when marginal osteophytes encroach upon the intervertebral foramen (right). The facet joints are then affected.

Symptoms The most common symptom is pain in the neck, worsening with exertion and relieved, in the early stages, by rest. This pain often radiates down to the hand, with numbness in the fingers or to the chest and shoulder blades depending the nerve root involved. The brachial plexus is affected. The trapezius becomes tender and painful. A nodule can form in the muscle due to chronic pressure. The symptoms of cervical cord compression can sometimes be severe. It can become continuous, making movements painful and limited. If the cervical vertebrae become unstable, the danger of cord compression is imminent and, in some cases, fusion of the bones may be warranted. However, this is not common.

Medical management Medical science accepts cervical spondylitis as a normal degenerative aging change. Painkillers are prescribed. In order to prevent the symptoms of vascular insufficiency, anti-platelet drugs are given to maintain cerebral blood flow. This makes the platelets less sticky, the blood thinner and helps better flow. While this is needed for immediate relief, long term issues need to be addressed. The essential change is of a mechanical nature. A normal state of blood flow would be restored if the cervical spine could be realigned and the intervertebral spaces widened (to a point). Physiotherapy can, at best, only offer marginal relief; sometimes the condition may even be aggravated. It is better avoided. In situations where the patient suffers acute giddiness, it is useful to restrict the movement of the neck with a soft collar. Sudden neck movements cause the spur to impinge on the cervical nerves and blood vessels and reduce the blood to the brain. This creates a situation where the patient sometimes becomes afraid of moving the neck. In the long run, of course, a collar is to be avoided as it stiffens the neck muscles and pushes the neck out of alignment. The problem is worsened as, the muscles and

bones have to be aligned and stretched rather than made stiff.

Fig. 164 Diagram showing the right vertebral artery coursing through the neck to the base of the brain.

Left: back bend (spinal extension) with double ropes helps elasticise the dorsal spine as well as all the spinal muscles in the shoulder blade and neck area. Back bend (spinal extension) in Tadasana with neck on rope (right) is highly specific for realigning the spinal curvature and abolishing vertebro-basilar insufficiency.

Cervical traction, where the skull is lifted up, has its value in a few cases. In due course, the weight of the skull makes it settle down on the cervical column and the symptoms recur. Though, obviously, the osteophytes remain, one can adjust and realign the spine so that compression of the vertebral arteries and cervical nerves does not occur.

Yogic management Patients with cervical spondylitis have stiff neck and trapezius muscles and are unable to stretch the neck backward. This is an inherent problem and not just a muscle spasm. As the anterior surfaces of the vertebrae are compressed causing pain, spinal extension relieves the problem, though the movement might initially cause vertebro-basilar insufficiency in some cases. The special way in which this stretch is done is shown in the illustrations above. Vertebro-basilar insufficiency is prevented because of the resultant elasticity of the cervical muscles and vertebral arteries. It is essential to make the trapezius, cervical and shoulder muscles flexible. Patients with cervical spondylitis cannot stretch the dorsal spine. Once this is accomplished, cervical spondylitis ceases to be a problem as extension movements reduce pressure on the cervical nerves. Again, by regularly practicing back bends, this disorder can be averted.

In yoga, the inter-vertebral spaces are widened by pulling the trapezius and other muscles downwards. This is yogic traction. This lengthens the trapezius for it is along the line of gravity (see illustration, facing page). Very little is achieved by conventional traction, where the muscles will telescope into each other again.

Holding window bar in Tadasana.

Shoulder stand with chair elasticise the arms, relieving radiating pain. Shoulder stand also gets rid of vertebro-basilar insufficiency and is essential for curing cervical spondylitis.

There are various asanas which prevent and give relief to this problem—Sarvangasana, Halasana and back bends are significant. Standing poses help align the cervical and dorsal vertebrae. Inverted poses like Head stand and Shoulder stand strengthen the cervical muscles and shoulder area. The technique used in these cases is quite different from the normal. In Head stand the forehead, (and not the centre of the skull), is placed on the ground. This lengthens the cervical column and helps weight bearing. Hence the concept that persons with cervical ailments should avoid Head stand is incorrect. The correct method should be learnt, taking the ailment into account. As the condition improves, normal practice methods can be introduced. Thus elasticity of the cervical muscles is ensured. Shoulder stand is done with the help of the chair. This releases tight trapezius muscles and frees all the structures along the cervical spine. If the normal method of Shoulder stand is practiced by the patient, injury can occur to the cervical spine. A rolled blanket may help the neck if stiffness is excessive. In Halasana, the cervical column is elongated and given strength and alignment. The dorsal spine is strengthened and made supple. In back bends like Urdhva Dhanurasana and Viparita Dandasana, maximum freedom is given to the anterior surfaces of the cervical column and the dorsal spine. Nerve compression is released. For a patient with cervical spondylitis these poses are modified. A simple exercise is to suspend the neck on the rope (page 419). This helps even aged persons get relief. This

single position provides relief from the symptom of vertebro-basilar insufficiency as the spine is made to fall into the anatomical line and blood courses normally into the back of the brain. Belts are used to make the shoulder and cervical muscles supple in a passive manner. This relieves nerve root compression in certain areas. Backward elasticity of the shoulders is very important. This releases compression of the cervical nerves. The hands are made to hold bars with the palms facing downwards (see illustration on previous page). This opens out the sternum and dorsal spine. If the dorsal spine is well elasticized, the symptoms are controlled. Twisting asanas are very useful to loosen the dorsal and cervical spine. In many, the rotators of the spine are very stiff and the neck is hardly able to perform normal everyday functions. These asanas help relieve stiffness and pain, and make the rotators of the neck soft and supple. In summary, the entire cervical column is made mechanically sound, so that movements are free and the symptoms are relieved. The specific asanas recommended for the treatment of cervical spondylitis are Bharadvajasana on the stool (refer section on yoga for the golfer), the double rope back bend, cervical extension with the rope, Shoulder stand with the chair, holding the window grills behind the body, trapezius traction and strapping the hands behind the back. The last relieves pain in the trapezius, cervical and mid-dorsal muscles, regardless of whether the pain is a referred pain or a localized one. Later, as recovery occurs, all asanas can be done. Back bends are very useful along with hand and elbow stand in younger patients. Some of the useful asanas are illustrated here.

Traction with rope levels asymmetrical trapezius muscles, relieving pain in the root of the neck.

Low back pain Nine out of ten persons have had at least one episode of low back pain. The human being is an erect species and this is erroneously thought to be a predisposing factor. It is possible to live without back pain. One has to know the techniques for this: not the usual guidelines to avoid bending forward, or lifting heavy weights and so on, but a thorough knowledge of the asanas that benefit the back and

proper performance of the postures. A good understanding of the mechanics of standing and sitting is also needed as the IT industry has contributed to excessive working hours. Before embarking on a detailed discussion of low back pain, let us review the causes for this condition. Apart from a protruded disc, there are a number of conditions that cause low back pain (fig 165). I have listed them below: — degenerative changes of the spine: arthritis, spondylosis, etc; — strains, sprains and fractures of the spinal bones; — tumors of the spinal cord; — tumors of the spinal and pelvic bones; — infections of the spine;

Fig. 165 Conditions, other than protruding discs, that cause pain in the lower back or leg.

— ankylosing spondylitis, the so-called ‘bamboo spine’ where the entire column becomes calcified and movement is nil in the late stages; — any malignancy with spread to the spinal column as in breast cancer, tumors of the abdominal and pelvic viscera, chronic prostatitis in the male; — blockage of the blood vessels; — arthritis of the hip; — gynecological conditions: pro-lapsed uterus, painful periods, pregnancy; — menopausal bone disease: osteoporosis, Paget’s disease where the condition is one of faulty remodeling of bone which is abnormally fragile.

What leads to low back pain? I. Local pain is usually caused by any process that irritates structures that contain nerve endings. The process can be any of the above listed factors, but in this discussion I am concerned solely with mechanical low back pain due to asymmetric and tight muscles and ligaments as this is by far the most common cause. II. Referred pain is pain arising in one area manifesting in another. For example, if the patient suffers from pancreatic disease or acid peptic disease, the pain may be referred to the back of the spine behind the stomach region. Pain due to lumbar disease is felt in the groin and thigh. This is due to the areas being innervated by the same nerves. The logic is similar to the shock felt in one part of the house when there is a short-circuit of electrical wiring at some other point. III. Root pain is due to compression of the nerve roots as they emerge from the spinal canal. Characteristically, anything that aggravates intra-spinal pressure, like sneezing, coughing, or straining, aggravates the pain. Other maneuvers like stretching the leg while supine stress the lower back (if the muscles are under spasm) and provoke root pain. If the third and fourth lumbar nerves are involved, the patient may complain of pain in the front of the thigh. If the fifth lumbar and first sacral nerve roots are affected, the patient may not be able to extend the big toe of the affected foot upwards. IV. Muscle spasm pain is in relation to local pain. If the patient is suffering from a chronic low back disorder, the involved muscles may be very tight and inelastic, swollen, nodular and resistant to any attempt at stretching. On examination of the patient and looking for certain signs, a diagnosis is made. Of importance is limitation of movement in several directions. This depends on the height of the patient, whether slim or fat, and the relative flexibility of the various spinal and hip joint muscles. The patient may have fairly complete spinal movements and yet suffer from pain. The common sites of pain are indicated in fig 166.

Fig. 166 Typical locations of tenderness in relatively superficial back muscles, following sprains of their myotendinous junctions. Left: Tenderness in the iliocostalis lumborum pars thoracis, near the costal attachments of its fascicles. Right: Tenderness in the longissimus thoracis pars lumborum where its fibres form the lumbar intermuscular aponeurosis. [Diagram reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

A preliminary radiograph may reveal some abnormality. A CT scan or MRI, along with other relevant investigations, may be needed in certain cases to establish the diagnosis. If no pathology can be identified, the cause is of a mechanical nature. If a cause is found, the remedy is to treat the cause. For example, if a tumor is pressing on the spinal cord, it is to be removed. If there is an infection of the spine like tuberculosis, the appropriate drug is instituted. If the spinal anatomy has been destroyed due to infection, surgical correction and restoration of the anatomy to as near normal as possible is to be carried out to prevent pressure on the spinal cord and subsequent paralysis.

Mechanical low back pain By far the majority of patients suffer mechanical low back pain. This is due to stiffness of the low back muscles. The stiffness includes limitation in rotation, flexion, lateral flexion and backward bending movements. This stiffness can run in families. Many persons have thick set muscles and broad frames, though not necessarily being on the fat side. More often this stiffness is acquired due to poor posture over the years and lack of exercise which makes the muscles tighter. A sudden strenuous activity results in snapping of the muscles of the back. Some have a slender build and are thus prone to low back disorders as the spinal muscles are too long (if they are tall individuals) and thin to be strong for postural activity. Such persons suffer recurrent pain all through the back, from the cervical to the lumbar region, on maintaining a fixed posture such as sitting or standing. The slender category are usually very flexible (though there are exceptions), and flexibility should be not be encouraged in this group as it would further reduce muscle strength. In contrast is the person who is very stiff and of a moderate build, who benefits by exercises which improve muscle flexibility. It is easier to induce flexibility in muscles that are tight than to make flexible muscles tighter. The latter often takes a very long time. If the slender person gains weight and broadens, the muscles become stronger. In other words, there is a specific geometry of shape, strength, rigidity and flexibility that determines the susceptibility to mechanical low back disorders. Obviously, our growth patterns are not under voluntary control but are endocrinal and genetic. A healthy understanding of body geometry and its impact on low back pain is important. Importance of posture and proper muscle tone The importance of good posture has to a certain extent been dealt with in the chapter on prolapsed disc. Sitting hunched in a chair, rounding the lumbar region, increases pressure on the muscles and produces muscle fatigue. Over the years the muscles tighten. Caving of the chest while sitting produces a deformity of the dorsal spine leading to premature degenerative changes. Poor mattresses, curling up into the fetal position while sleeping, oversleeping, are some of the other habits that make for stiff and unhealthy muscle tone.

My youngest patient with a low back problem was 14 years old. This is hardly the age to suffer such a health problem. Enquiry revealed that the patient rarely exercised or participated in any kind of body movement even in school, postural patterns were poor and added to this was a lack of awareness of the impact of all this. Many of us are not aware of our body posture, the way we move, sit or stand. This is very important as it affects mechanical stability. It requires not medical knowledge, but common sense and constant observation. Basic body sense should be inculcated in children. Many of us, when we stand, push the stomach out, curving the lumbar spine forward. The pelvic and abdominal organs are pushed forward. The muscles, subjected to a kind of backward bend, become unhealthy and stiff. When we sit, the shoulders are often drawn up, compressing the cervical nerves and vertebrae in the long run. Some of us are naturally flexible in bending forward and others while bending backward. The levels of flexibility can sometimes be as good as in a trained individual. The exact reason is still not understood but patterns of daily usage certainly influence this condition to some extent. It is important to maintain a certain degree of flexibility and rigidity to avoid low back pain. Excessive rigidity or flexibility is both harmful. A violin string that is too tight can snap during usage and one that is too loose does not have the right resonance. It is not important to practice all the complicated asanas to prevent back pain, but a few important ones are necessary. For example, in bending forward, it is essential that a person be able to touch the floor with ease and, in sitting and bending forward, it is essential to master Paschimottanasana. For lateral bending, standing postures are invaluable. For rotational flexibility, Marichyasana or Ardha Matsyendrasana is important. For flexibility in the backward direction, Urdhva Dhanurasana is useful. Low back pain can result if the abdominal muscles are weak, whether or not one has a sagging abdomen, as the abdomen drags the spine forward producing constant traction on the spinal muscles. This is why some women develop low back pain for the first time during pregnancy: the muscles of the lower back are not strong enough to resist the force of the pregnant uterus pulling the spine forward. If these muscles are excessively trained and hardened as in body builders, the spine becomes rigid as the diaphragm which is attached to the abdominal muscles becomes inflexible. When we sit or stand, the muscles of the back are in constant activity to maintain the posture. If a person’s occupation requires constant sitting, certain parts of the body are overused. This leads to overstraining of the other muscles. For example, a violinist playing in the sitting position has no opportunity to bend back but only forward. Over the years the spinal muscles cannot stretch backwards. Thus, a certain range of movement and functional capacity is lost. A computer professional who sits in front of the screen all day has contracted hamstring muscles as the thigh is constantly flexed.

Fig. 167: The lumbar fibres of iliocostalis (iliocostalis lumborum pars lumborum). On the left, the four lumbar fascicles of iliocostalis are shown. On the right, their span and attachments are indicated by the lines.

Fig. 168: The thoracic fibres of iliocostalis lumborum (iliocostalis lumborum pars thoracis). The intact fascicles are shown on the left and their span is shown on the right. The caudal tendons of the fascicles collectively form the lateral parts of the erector spine aponeurosis (ESA). [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

Repetitive contraction or repetitive stretching of a muscle is harmful if steps are not taken to use the body in the opposite direction. If a muscle is maintained in the same posture or used in a repetitive movement, the consistency of the muscle changes over the years. Muscles have a visco-elastic property. Excessive one-sided strain harms healthy functioning. Circulation is hampered and so is

proper oxygenation. As use of the muscle in the opposite direction is avoided, a minor movement in that direction may precipitate a strain or a tear due to muscle stiffness. Hence harmonious usage is essential. Before we proceed further, it is important for us to understand briefly the functional anatomy of the muscles of the back. The muscles of the lumbar region consist of extensors, rotators, lateral flexors, etc. A thick tissue (the thoraco-lumbar fascia) covers the deep muscles of the back. The manner of arrangement of this fascia is as follows: it originates from the spines of the vertebrae and is attached to the ribs; in the lumbar region the fascia is arranged in three layers.

Fig. 169: The lumbar fibres of longissimus (longissimus thoracis pars lumborum). On the left, the five fascicles of the intact muscle are drawn. The formation of the lumbar intermuscular aponeurosis (LIA) by the lumbar fascicles of longissimus is depicted. On the right, the lines indicate the attachments and span of the fascicles.

Fig. 170: The thoracic fibres of longissimus (longissimus thoracis pars thoracis). The intact fascicles are shown on the left. The darkened areas represent the short muscle bellies of each fascicle. The short rostral tendons of each fascicle and the long caudal tendons collectively constitute most of the erector spinae aponeurosis (ESA). The span of the individual fascicles is indicated on the right. [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

We must understand the anatomy of the deep muscles of the back. The muscles include those that move the head and neck, and the complex erector spinae group that move the vertebral column. It is the erector spinae and the transverso-spinalis groups that are important. Originating from the sacrum and spines of the lumbar and 11th and 12th dorsal vertebrae, the erector spinae splits in the lumbar region into three parts: lateral (outer), medial (near the midline of the body) and intermediate (between the two). The lateral part is known as the iliocostalis. This has a lumbar part (fig 167), attached to the lower six or seven ribs; a thoracic part (fig 168) starting from the lower six ribs and attached to the upper six ribs and the seventh cervical vertebrae; and a cervical part which starts from ribs 3, 4, 5 and 6 to attach itself to the 4th, 5th and 6th cervical vertebrae. The intermediate part is the longissimus. This is the largest continuation of the erector spinae. It is attached to the lumbar vertebrae (their transverse processes) in the thoracic region to the tips of the transverse processes of all the thoracic vertebrae (figs 169, 170), and in the cervical region from the 2nd to 6th cervical vertebrae.

Fig. 171 The erector spinae aponeurosis (ESA). This broad sheet is formed by the caudal tendons of the thoracic fibres of longissimus thoracis (LT) and iliocostalis lumborum (IL). [Diagram reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

The central part of the erector spinae is the spinalis muscle. This is attached to the 1st and 2nd lumbar vertebrae, 11th and 12th thoracic vertebrae and, in the cervical part, to the other muscles (fig 171). The iliocostalis extends the vertebral column and provides lateral flexion. The longissimus bends the spine backwards and laterally. The spinalis is the extensor of the vertebral column. The next group is that of the transverse- spinalis muscles which have a cervical and a thoracic part. The latter arises from the thoracic vertebrae and inserts into the spines of the cervical vertebrae. This group of muscles extends the cervical and thoracic parts of the vertebral column and rotates the column to the opposite side. The multifidus, lying deep to the above group, is a thick fleshy muscle which starts from the lumbar spinous processes and inserts below, along the lumbar vertebrae till the sacrum (fig 172). The rotators, which are below the multifidus, are best developed in the thoracic part: the thoracics are 11 in number on each side and connect from the 1st and 2nd thoracic vertebrae to the 11th and 12th. The interspinalis are short muscles which connect the spinous processes of adjacent lumbar vertebrae. There are four pairs in the lumbar region.

The multifidus and rotators are capable of extending and rotating the spinal column. Muscles of the abdomen These are principally four: the external oblique, the internal oblique, the transverses abdominus, and the rectus abdominus. The most external of the muscles (see diagram in section on anatomy), the external oblique, is attached to the ribs above and the pelvis below. Most of this muscle forms an ‘aponeurosis’ (thick tissue) which is inserted into the pubic bone. Internal to this is the internal oblique. It starts from the thoraco-lumbar fascia and the pelvic bone and attaches to the tissue of the former muscle and the next. Its upper part is attached to ribs 7, 8 and 9. The transverses are the innermost of the abdominal muscles. It arises from the lower six ribs on the internal aspect, and the pelvic bone. The muscles join with the previous ones (internal oblique) and part of this combination passes behind the rectus abdominus to cover it from behind. This arrangement is the same on both sides of the body. The rectus abdominus is the largest. This can be appreciated in body builders and in a healthy lean male. It forms the sagging abdomen—the so-called ‘paunch’— if it is overstretched due to lack of proper tone. The muscle arises from the pubic bone and is attached to the ribs above. It is enclosed in a sheath of aponeurosis formed in front by the first two muscles (external and internal oblique) and at the back by the second and third. Below a certain anatomical landmark, on the abdomen, the aponeurotic tissue of all three muscles passes in front of the rectus. This provides strong protection to the abdominal organs. Action of the abdominal muscles The principal action of these muscles is to press on the abdominal organs when the thorax and pelvis are fixed, as in straining during evacuation or when lifting a heavy weight. If not for this bracing action, the abdominal organs can prolapse downwards. Hence, weightlifters wear a tight brace that not only supports the spinal muscles but also the abdominal organs. When the pelvis is fixed, the muscles flex the upper part of the body and when the vertebral column is fixed, the muscles flex the pelvis. They also flex the column towards one side and serve to rotate the spine to the same or opposite side. In general, the obliques are concerned with forcible twisting movements and the rectus in flexion when resistance has to be overcome. The rectus sheath can be hardened if a blow on the abdomen is attempted. The rectus flexes the spinal column; with the oblique, it flexes the spine obliquely. The diaphragm It is important here to understand the role of the diaphragm. This is a partition that separates the contents of the thoracic from the abdominal cavity. In front, this sheet of muscle is attached to the inner surface of the lower end of the breast bone (sternum) and the inner surfaces of the lower six ribs. Behind, it is attached to the transverses abdominus muscle and the transverse process of the first lumbar vertebra.

When the lungs expand, the muscle moves downwards and it compresses and massages the abdominal organs. This facilitates expulsion of waste matter. When the lungs move upwards (during exhalation), the diaphragm moves up helping to complete the expulsion of air from the lungs. The muscle has three holes in it to allow passage of the esophagus, the aorta which supplies blood to the rest of the body, and the inferior vena cava which carries impure blood from the lower half of the body to the heart and lungs for purification. When there is back muscle spasm, the diaphragmatic fibers are also tense owing to the lumbar attachment. When a person with an acute back problem tries to bend forward, the abdominal muscles tend to contract immediately. Unless this factor is kept in mind when remedial exercises are given, the condition will not improve. As the spasm in the diaphragmatic fibers decreases, the spinal muscles also become less taut (fig 173).

Fig. 172 The component fascicles of the multifidus. A : the laminar fibres of multifidus; B to F: the fascicles from the L1 to L5 spinous processes respectively. [Diagram reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

We can now understand how intricate is the arrangement of the spinal muscles and how orderly the movement in coordination with different muscle groups. I will explain the motions of flexion, extension, lateral bending and rotation which are the principal movements of the spine. When we move, sit or stand, muscle activity is so automatic that we tend to take it for granted. It is important that the spine be kept flexible in all directions. Hence, the important advice is to practice a few asanas in each direction. Exercising the back muscles must never be in a jerky manner. A steady state of stretch or contraction is more conducive to tissue health.

Fig. 173 The diaphragm.

The normal physiological response of a muscle to an initial stretching stimulus is to resist the stretch. If the stretch is maintained for a certain period of time, the muscle gently elongates, the resistance diminishes and electro-physiologically the entire muscle is quiet. Blood flow to the muscle is increased. The quality of flow soothes the cells. Daily practice maintains the softness and hardness of muscles. Proper toning occurs. In dynamic jerky stretches (the muscle being stretched and immediately contracted before it has had time to adjust its reaction to the initial stretch), the muscle contracts to a smaller length than the initial, i.e., before the exercise started and the next day the muscle is tighter. Hence, frequent tears are more common in jerky exercises. This never happens in steady state practice as there is no momentum produced (movement is absent) to damage the muscle. Flexibility programs (which do not mean only stretching but both rigidity and flexibility) are very important. More important is alignment in muscle stretches. Every muscle has a certain anatomical direction in which it has to be stretched. Deviation from this can cause injuries.

Symptoms of the patient The most pressing complaint is that of pain. The nature of pain may be dull, stabbing, diffuse or a combination of all these. This can be localized in the area of the pathology pointed out by the patient.

The pain may begin suddenly without any previous history. The situation may be similar to that of a slipped disc in that the back ‘freezes’ when the patient bends down to pick up something. Or, the pain may be brought on by a sudden violent sneezing bout, to persist thereafter. Depending on the patient’s threshold of pain, it is described as mild, moderate or severe. The pain varies from time to time. It can be worse in the early mornings to get milder at the end of the day, or vice versa. As the body is maintained in a fixed position for many hours during sleep, the muscles tend to stiffen. This can increase the pain. During the day, movement releases muscle spasm, and the pain lessens. The pain is aggravated by driving, poor posture while sitting or standing, riding a two-wheeler; jogging or walking definitely inflame the pain-usually not during the movement, but hours later. Pain may be related to specific directional movements. It waxes and wanes, disappearing after a variable period of time or becoming a chronic ailment. Occupational low back pain is a common in people who maintain the same posture for many hours. The patient is able to localize the pain accurately. It can be in the lower back centrally, or to the sides, or the entire lower back. It may radiate to the buttock if a nerve is pressurized at a higher level, or to the leg. Degenerative spinal joint disease can cause pressurization of the nerve roots in the spinal canal without concurrent disc disease. Hence, we see the radiation of pain. Stiffness is the other principal symptom. The patient complains of limitation of movement in specific directions. Like the pain factor, stiffness varies from time to time. An air-conditioned atmosphere can definitely stiffen the muscles. The third factor is limitation of movement. The patient may complain of restriction in flexion, or bending the spine backward or sideward, or a combination of bending forward and rotation. The pain may be aggravated by any of these movements.

Medical management Relieving the pain is the first and foremost job of the physician. This might require rest in bed for a few days or, in severe cases, a few weeks, along with analgesics to relieve pain. If the pain started after lifting a heavy object, the injury may be more severe. The proper method of lifting should be followed. It is necessary to bend the knee, but it is more important to take the load of the object on the biceps muscle and not the back in the process of lifting. The spine can, and has to be, stretched forward (there is no need to keep an erect spine) and not bent forward which, if it happens, is the sole cause of injury. Moreover, even if the technique is right, if the weight is more than the person’s body can manage (for the height of the body, strength of the bones, and thickness of the spinal muscles), injury can result.

Pawana Muktasana on stool with pillow combines flexion and rotation. It is easy for patients to execute.

Bharadwajasana on chair is simple and effective, loosens the spinal muscles and provides immediate relief.

The mattresses used for sleeping must be hard and supportive. As early as possible, the patient must be weaned off analgesics, and exercises should be instituted to strengthen the spine. Pain may still persist when the exercises are begun. As the muscles are stretched and soothed, the pain lessens. Of course, it is harmful to exercise when there is too much pain. But it is important to understand that too much rest is counter-productive as it further stiffens the tissues. Within limits of pain, exercise must be begun, and monitored by the physician. When an injury occurs the tissues are contracted. If left alone, a kind of permanent tightness occurs to the tissues which resist stretching later. It is this

situation that causes pain at the first attempt. The patient may not be aware whether the pain which increases during exercise is due to wrong techniques applied, or a healthy kind of pain due to initial attempts. This requires the guidance of a qualified physician. Usually, healthy pain disappears after a few days. The wrong kind worsens. If we are sensitive to our body, it is possible to differentiate between the two kinds of pain. So pains are not all good or all bad. When a healthy person attempts a hamstring stretch on the first day, he will experience pain and soreness of a certain kind results for a few days. One must understand why the pain arose and not avoid exercising just because pain persists.

Supta Padangusthasana against a wall elasticises the hamstring muscles; as it is done with support, it also relieves lower lumbar pain.

Dog pose with rope is simple and safe, providing aligned traction to lumbar muscles and removing pain very quickly.

Standing Marichyasana with footrest loosens stiff spinal rotators.

Exercises prescribed according to medical concepts are not always useful as they lack range of movement and certain anatomical tenets are not followed. For example, if the thighs are flexed and brought to touch the stomach, it stretches the spine; but there are many points to observe on how the abdominal muscles should be used, whether or not the thighs should be kept together, manner of breathing, etc. Extension exercises done with an injured back will most certainly aggravate the pain in the majority of cases. The action of muscles in this pose is against gravity and, as the back is already weak, any strain in this direction causes more pain. To build strength on the spinal muscles it is essential to remove pain by different postures and then load the spinal muscles by lifting the legs using postures such as Salabasana. In a small proportion of patients, extension exercises do relieve pain. It only means that the spine was ready to practice them. Stretching the hamstrings to improve tone and flexibility is important for a patient with low back pain, especially if the muscles are tight. Generally, the patient is advised to lift and raise the leg as high as possible in the hope of stretching the muscle. But this method will not

improve flexibility as the leg cannot be stretched without being pulled up (see illustration of Supta Padangusthasana in the section on slipped disc). Moreover, the position of the pelvis, the position of the leg on the floor, the position of the inner groin of the stretched leg, all have to be carefully adjusted.

Yogic management Here also, relieving the pain forms the main object of management. Acute pain needs medication. Yoga has to be started only after this reduction of pain. Unless rehabilitation is done, the patient can never recover fully. The pain may subside, but deep-seated dysfunction will persist. Simple asanas like Pavanamuktasana with pillows, Uttanasana with support, progressing to twisting postures near the wall like Bharadvajasana and Marichyasana, Dog pose, stretching the hamstrings in Hasta and Supta Padangusthasana with assistance, are necessary (illustrations on page 433, page 444).

Trikonasana (left) and Parsvakonasana (right), done obliquely with ropes, make supple the lateral spinal muscles and lengthen the spine, providing pain relief.

Depending on the clinical condition and age group of the patient, the nature of the body with regard to flexibility and rigidity, recovery can be expected in three to eight weeks. Thereafter, the patient should continue to practice yoga without discontinuance, as the condition may recur. This does not mean that the situation is incurable; but in order to prevent degeneration and deconditioning of muscles, which occur rapidly with lack of regular exercise, maintenance of therapy is essential. All standing poses are very useful to contract, stretch and strengthen the spinal muscles and to relieve pain. For some, standing poses may have to be done in an oblique manner to relieve pain (illustrations previous page). Props can be used whenever needed. The horse prop is invaluable for this. The patient must learn not to overstretch or under stretch the muscles; neither is conducive to the health of the spine. Dog pose is invaluable, starting with the rope (if needed) and later managing without it. The range and geometry of movements are far more sophisticated in yoga, which is methodical in its approach. If the patient is regular in practice, a pain-free back is possible. The female body is normally softer and suppler, due to hormonal reasons. But, now, women are as stiff as men due to faulty posture and lack of exercise, particularly flexibility enhancing ones. During the menstrual cycle, women can practice certain exercises to relieve back pain; if the pain is severe, all recommended asanas can be practiced. Full flexibility in forward bends, particularly a seated forward bend like Janu Sirsasana (standing forward bends are easier to achieve than seated forward bends as the spine is assisted by gravity in standing poses as one bends down), well performed standing poses, seated twisting poses, back bends like Urdhva Dhanurasana give a pain free back. Initially the exercises are used to gently stretch the muscle under pain, which is generally constricted. Hence the exercises work like traction which creates space. Later, after a certain range of movement is achieved, both contraction and extension of the muscles are necessary.

There are times no amount of exercise will help when a muscle is under spasm. Even rest and analgesics may not help to the needed extent. The patient must understand when to give rest to the body, when to use an analgesic, when to exercise. Patience and perseverance are needed to ensure full recovery. All the asanas mentioned below for providing relief from a prolapsed disc problem are useful for low back pain.

Lumbar disc prolapse This is a problem where the nucleus-pulposus of the inter-vertebral disc is forced out of the annulus fibrosus due to mechanical forces increasing intra-discal pressure or rise in tension at many other anatomical points along the spinal column. The incidence of this problem has been rising steadily and, today, every three out of five human beings have had an episode of slipped disc. Before we proceed further, it is essential to understand the functional anatomy of the lumbar area in detail; this will help us understand better the pathogenesis and management of a prolapsed disc. Functionally, the lumbar vertebrae can be divided into three parts: (i) the vertebral body; (ii) the pedicles; and (iii) the posterior elements consisting of the laminae and articular and spinous processes (figs 174, 175, 176). The vertebral body serves weight-bearing purposes and is well designed for this. The internal structure is also suited to this. The interior is not solid bone but a cavity with struts in various directions. These are called trabeculae which bear loads (fig 177). The pedicles connect the posterior elements to the vertebral body proper. They transmit tension and bending forces.

Fig. 174: Lumbar vertebra, top view. VB: vertebral body; vf: vertebral foramen; NA: neural arch; SP: spinous process;

L: lamina; MP: mamillary process; SAP: superior articular process; TP: transverse process; P: pedicle; RA: ring apophysis.

Fig. 175: Division of a lumbar vertebra into its three functional components. [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

Fig. 176: Joints between two lumbar vertebrae, lateral view.

Fig. 177: Internal architecture of vertebral body: transverse connections prevent the vertical struts from bowing and increase the load-bearing capacity of the box.

Fig. 178: Zygapophyseal joints L3-4, posterior view. On the left, the capsule of the joint (C) is intact. On the right, the posterior capsule has been resected to reveal the joint cavity, the articular cartilages (AC) and the line of attachment of the joint capsule (broken lines). The upper joint capsule (C) attaches further from the articular margin than the posterior capsule. [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

The posterior elements are irregular masses of bone projecting in all directions. The processes provide attachment for muscles. All spinal muscles are attached to these processes. Thus, movements of muscles determine the strain on the vertebral bodies. The laminae make for stability between two vertebral bodies and provide for proper transmission of forces of movement. When two lumbar vertebrae join they form three joints. The joints between the articular processes of each vertebra (fig 178) are known as zygapophyseal joints, right and left (also known as facet joints). The other joint is between the vertebral bodies.

Anatomy of the disc An inter-vertebral disc is made up of a central part known as a nucleus pulposus and a peripheral part, the annulus fibrosus. The two are in anatomical continuity. The disc is protected at the top and bottom by cartilages known as endplates. The pulposus is a jelly-like mass, deformable, and is 70% to 90% water, protein and collagen. The annulus is a tough material consisting of collagen arranged in concentric rings at geometric angles. It also contains elastic fibers. The endplates contain similar constituents (fig 180).

Fig. 179 Function of the intervertebral disc. With its contained gelatinous nucleus pulposus, the disc serves a cushioning purpose.

Functions of the disc The disc is deformable to a certain extent. The disc serves as a cushion between two vertebrae. It transmits weight from one vertebra to the next (fig 179). The central pulp deforms but the annulus restrains any expansion of the pulp under pressure. Pressure distends the annulus and the endplates. Hence, the disc is like a spring and a shock absorber. The ligaments of the spine These are several in number: i. The ligaments that connect the vertebral bodies: these are in front and back of the spinal column, covering the front portion and the back portion of the discs respectively, and giving stability. They are collagen fibers. They are known as the anterior and posterior longitudinal ligaments (figs 181, 182). ii. The ligamentum flavum, which are heavy and thick and connect the laminae of each vertebra, provide stability and transmission of forces (fig 183). iii. Interspinous ligaments, which connect adjacent spinous processes, serve to resist separation of the vertebral bodies during flexion of the spine.

Fig. 180 Structure of an intervertebral disc. The nucleus pulposus is the central gelatinous part of the disc enclosed in several layers of cartilaginous laminae. The nucleus hardens with old age.

Fig 181: The anterior longitudinal ligament (ALL) and the inter-transverse ligaments (ITL). The arrows indicate the span of various fibres in the anterior longitudinal ligament stemming from the L5 vertebra.

Fig 182: A median sagittal section of the lumbar spine to show its various ligaments. ALL: anterior longitudinal ligament; PLL: posterior longitudinal ligament; SSL: supraspinous ligament; ISL: interspinous ligament; v: ventral part; m: middle part; d: dorsal part; LF: ligamentum flavum, viewed from within the vertebral canal and in sagittal section at the midline.

Fig 183 The ligamentum flavum at the L2-3 level: anterior view (from within the vertebral canal) showing the medial (M) and lateral (L) divisions of the ligament. The shaded areas depict the sites of attachment of the ligamentum flavum at the levels above and below L2-3. The silhouettes of the lamina and inferior articular processes behind the ligament are indicated by dotted lines. [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

There are many other ligaments but these are the most important for us to understand the biomechanics of the spine.

Aging of the disc This occurs at the biochemical and histological level, affecting the mechanical properties of the disc. The number of elastic fibers decreases and that of the collagen fibers increases. The water content decreases. The disc becomes less resilient and efficient for mechanical functions. A fibrous change occurs. Weight and force transmission are affected. The endplates and the vertebral body become wasted. Weight transmission to other vertebrae is less efficient. The net result is that movements of the spine are unhealthy. Apart from this, if the individual has not maintained suppleness of the spinal muscles, excessive and unnatural stresses and strains on the spinal column are created. These produce stress fractures, disc prolapse, degenerative joint disease, osteoporosis, etc. It is also important to realize that the muscles of the spinal column and the joints degenerate as one grows older. The zygapophyseal joints become thin. Functional efficiency of the muscles reduces. This alters the biomechanical efficiency of the spinal column. Mobility of the spinal column reduces as one grows older. This definitely predisposes one to spinal problems.

The common picture The background is that of a very stiff spine and the situation is that of bending down to brush the teeth or to pick up an object from the floor. The person is ‘stuck’ in the posture and is unable to shift from that position. Severe pain in the lower back or the leg is the main symptom and often the patient has to be carried to bed. The pain may fluctuate from mild to severe. It can radiate to the legs due to pressure on the sciatic nerve which supplies the leg muscles. The pain is described variously as aching or needle-like pricks, or burning, or like an electric shock. The leg on the affected side could be immobile due to the pain. Bed rest is advised for a few days or weeks. In due course most of the patients recover. This picture is not the only typical one and variations can occur. The sciatic nerve pain may be mild. The low back pain may be absent after the initial bout, to be replaced only by the radiating pain or vice versa. An MRI or CT scan will reveal the herniated disc. Surgery is essential in only a small percentage of patients (around 5%). The majority do well after a few weeks of conservative management. Secondly, removal of the disc does not solve the problem. The pain in the lower back continues even after surgery. The reason is that the spinal muscles are very stiff and out of alignment which gives traction to the surrounding spinal nerves. The disc herniating is only an incidental factor, due to the pull exerted by the muscles, which continues even after disc removal. This is because of rigidity. Medical science has no parameters to predict the occurrence of prolapsed disc in a person. Yoga can predict, years ahead, whether or not a particular person will suffer from a prolapsed disc. The reasoning in each is completely different.

Mechanism of lumbar pain in a situation of disc prolapse Mechanical Distension of the annulus produces pain. The outer parts of the annulus are rich in nerves. If the inner pulp tracks from within to the peripheral parts of the disc, stretching of the annulus produces pain. The disc usually prolapses backward and to the side, left or right. The endplates, if injured, cause aberrant distribution of weight and other stresses of movement, over stressing other areas of the lumbar spine. Associated degenerative changes in the spine, pressing on the nerve roots, affect mechanical properties (figs 184, 185).

Fig 184: Compression injury of an intervertebral joint. Excessive compression force may result in fracture of a vertebral endplate. This lesion may heal and be of no consequence; on the other hand, it may initiate a process of disc degradation affecting the nucleus pulposus near the fracture site but gradually extending into the rest of the nucleus.

Fig 185 : Disc degradation and internal disc disruption. Disc degradation spreads to involve all of the nucleus pulposus. If the anulus fibrosus remains relatively intact, the disc narrows because of the loss in water-binding capacity of the nucleus, resulting in the condition of isolated disc resorption. On the other hand, degradation may spread radially into the anulus fibrosus, causing a fissure. The external appearance of the disc remains normal; the pathological process remains wholly within the disc and the condition is described as internal disc disruption. If the remaining fibres of the anulus fibrosus are breached, nuclear herniation may follow internal disc disruption. [Diagrams reproduced from Bogduk/Twomey, Clinical Anatomy of the Lumbar Spine; Courtesy: Churchill Livingstone, Publishers]

Chemical If the chemical contents of the disc leak out and touch the nerve roots, this can cause chemical irritation of the nerve roots. Edema of the nerves produces pain. Vascular The pressure of the prolapsed disc can compress adjacent veins and produce congestion. The nerves are particularly susceptible to venous congestion as they lack lymphatics which serve as an alternative source of fluid return.

A further analysis A glance at this would make us understand that the essential logic in a situation of slipped disc is to first loosen the muscles so that, in the process of loosening up, the disc and its spatial relationship to

the vertebral bodies and other structures is reestablished, the mechanical pressure released, the chemical irritation relieved, and the venous edema relieved. Yoga alters the spatial relationship of every organ, muscle, bone, nerve and tendon. The disc ruptures since the surrounding protecting structures, the muscles and ligaments are inelastic. If these are supple, the disc also aligns itself to the various directions of the body’s movements. In order to bend forward, the pelvis has to rotate over the ball of the hip joint. As the hamstrings are attached to the ischial tuberosity, if they cannot elongate, the pelvis cannot rotate forward. The spine bends downwards, overstretching the anatomical coverings of the disc, and rupture occurs. If the hamstrings are flexible, the pelvis can rotate and the spine stretches downwards, rather than bending. Then there is no danger of a disc rupture. In yoga, the hamstrings are made very flexible so that a disc prolapse cannot occur. Over flexibility of the body can also produce a disc prolapse as the necessary rigidity to retain the disc in place is absent. Hence a balance between flexibility and rigidity is important for health. On being advised not to bend forward, most patients suffer a fear complex, which makes the body rigid. They are constantly on guard, which tightens the muscles. An attempt to even lean forward can cause recurrent spasms, weakening self confidence. Unless trained to understand that stretching and bending are two different things, a patient will not get rid of this problem. Keeping the body arched to prevent a natural movement is harmful. Bending forward is a natural movement and if avoided leads to recurrent catches and atrophy of the spinal muscles. One must know when to stretch and when not to do so. Avoidance should not be permanent; then the patient will remain a patient always! The supplementary advice of keeping the spine erect when lifting a weight is illogical. One must bend forward, but the weight of the object must be transferred to the biceps and not to the back. The arms, not the spine, must lever the weight up. This prevents strain on the back. It is an unnatural posture to keep the spine straight when lifting weights. It is not a natural flow of spinal biomechanics. It also leads to stiffness of the muscles in the long run. The spine is suited to bend in many directions. Of all the ligaments, the inter-spinous ligaments are the weakest elements which succumb to flexion strains. The disc is quite resistant to injury unless the strain is excessive. Usually, with a background of stiff spinal muscles, the act of bending forward precipitates excessive strain on the endplate, breaking it and the other ligaments. This sets off a series of degenerative changes in the pulposus, which begin to push through the annulus in a radial direction (fig 185). If the muscles are not made flexible, repeated strain on the annulus (which bears excessive loads as the endplate is functionless) causes rupture of the annulus and herniation of the disc (fig 186). The disc, however, does not remain in a fixed place but has a certain range of mobility. This accounts for the variation in pain levels. If the disc moves away from a nerve, pain is reduced and vice versa.

Fig 186 Herniated disc (arrows indicate perceived pain paths along nerves).

When one side of the spine is stiffer than the other (as is the case with 90% to 95% of human beings), the disc herniates on that side. In order to neutralize this inequality of the rotator muscles, asanas with spinal rotations are necessary. These soften the spinal muscles and loosen the hip joints so that flexibility is gained. In such a process of rotation, calcification of the extruded disc material that happens with long standing prolapse is prevented. Mobility of the disc remains.

Symptoms The patient experiences severe, quite incapacitating pain in the lower back and in the thigh, calf or foot. The patient may not be able to move the affected leg at all due to nerve and muscle spasm. Specific movements of the body, like trying to stretch the big toe upwards may be affected. This means that the nerve supplying the muscle is under pressure. The pain in the lower back is due to spasm of the lumbar muscles with concurrent inflammation and also due to tears of the annulus and supporting ligaments of the intervertebral joints. Edema and other factors mentioned above also cause pain.

Fig 187 Contents of sciatic foramina.

The pain in the lower limb is known as ‘referred pain’. As the sciatic nerve innervates the lower limb and its root at the spinal level is irritated by the disc, the current of pain travels to the muscles innervated by that nerve and may be felt at any part of the limb depending on the nerve fiber affected. The point inside the buttock from where the sciatic nerve emerges (fig 187) is a tightly constricted area. The patient may have a tilted spine, to the left or right. This is to avoid pressure on the spinal nerve on the side of the herniated disc. Hence the tilt is to the opposite side of the pathology. On examination one may find the pelvis jutting to one side and the navel off centre, pulled towards the non-herniated side. This is a characteristic deformity in many patients. When standing erect, many of us stand by throwing the body weight on only one buttock—this requires careful observation. In most patients with a slipped disc, due to years of asymmetrical usage of the body in weight-bearing the muscles around the nerve go into spasm and pinch the nerve. This also produces pain down the leg. In a patient with a slipped disc, sciatic pain also occurs owing to malalignment of the piriformis muscle (fig 187). This is the ‘piriformis syndrome’. Restoration of alignment relieves pain. Constant

usage of only one side of the body produces pressure on the sciatic nerve. A simple example is that of a motorcyclist using the same leg to kick-start the vehicle. Over years the person invariably experiences pain in the buttock region. It is essential that we are all aware of our body movements in everyday activities, identify oft repeated movements and use the body fairly evenly, however insignificant the task may appear to be.

Medical management The patient is advised rest in bed for a few days or weeks, depending on the clinical situation. The bed should be hard and supportive to retain the natural curves of the body. Soft mattresses are unhealthy as the spinal muscles are not supported properly. Oral or parenteral analgesics may be needed. In many cases, the pain may take a few days to a few weeks to resolve. The decline in pain level is a gradual process. As soon as possible, exercises are introduced to help the muscles and nerves recover. In some cases, use of traction to relieve the compression on the nerve roots may be helpful. Traction produces an increase in length of the muscle and nerve. This relieves the pressure on the nerve and the cramped muscle, and pain reduces. But, in many cases, the pain is aggravated with traction. When medical traction is used for pain relief, it does not take into account the extent of muscular malalignment, which is why the pain increases. Most of us do not have symmetrical movements of the spine. Flexion may be limited, extension may be healthy, rotations may be asymmetrical. All this determines the health of the spine and the distribution of biomechanical forces in different directions with different muscles. This also determines the nature of the clinical situation, severity of pain and recovery. If traction is used, it is better that it is intermittent and not uncontrolled in its action on the spinal muscles. If the force is maintained for hours at a stretch, the muscles weaken, and can go into spasm with increased pain, especially in a patient with rigid muscles. The muscles are also pulled in the wrong direction as alignment is not taken into account in the application of traction. Sometimes no relief occurs even if recurrent traction is given. Even a healthy person finds it very strenuous to maintain a muscle in its stretched position for just a few minutes, not to talk of a few hours. It is natural that a patient, therefore, experiences greater pain at times. If conservative management fails, surgery may be needed. But as I have mentioned before, it is possible to avoid this in most situations. As the essential logic in development of a disc pathology is of a biomechanical nature, similar principles should be applied in treatment. Removal of the disc, therefore, is treating only the effect of the situation. The cause is imperfect spinal biomechanics. Hence, in many patients, pain persists even after surgery. Rehabilitation of such patients is difficult, as the tissues are never the same after surgery. Even after microsurgery, it is essential that healthy spinal biomechanics be re-established. If not, the situation may recur after many years. In a procedure like laminectomy (excision of a vertebral lamina), the structural stability of the spine is interfered with as part of the vertebral anatomy is removed. This can cause pressure from the segments above which will again produce pain. Moreover, after surgery, degenerative joint disease develops rapidly if proper rehabilitative methods are not resorted to. If a patient is free of pain after

surgery, it is that the body has been able to adjust biomechanically. In my experience, the majority do not fall into this category. It is also difficult to predict the success of the surgical procedure. There are certain parameters for which alone surgery is needed. Though, according to medical concepts, it is impossible to predict the future for a patient with a disc prolapse before or after surgery, in the eyes of yoga it is certainly possible to look forward to a very comfortable future.

Bharadwajasana near wall, with rope.

standing Marichyasana with footrest are essential to realign the disc. Decompression of spinal nerves occurs. The rope technique is invaluable for stiff persons, while the standing posture provides quicker relief.

Drugs do not play any role in the treatment of disc prolapse except for a short period in the relief of pain and inflammation. The use of a hot water bag is permissible. This should not be for more than ten minutes as the heated muscle cools down later and becomes very stiff. As soon as the patient has stabilised with adequate rest and analgesics, exercises must be begun. Exercises work along the principle of natural traction due to the manner of execution and the geometry of the pose. In certain situations, exercises have to be instituted even if the pain has not abated. Acute pain always needs rest. Chronic pain can be treated with exercises, but an acute exacerbation of chronic pain may need rest and analgesics, followed by exercises.

Yogic management The horse prop is invaluable for the patient to secure relief. All standing asanas elongate the muscles of the spine. Lateral bending asanas like Trikonasana and Parsvakonasana are very useful in lateral disc prolapse where the disc can be massaged. The compensatory spinal tilt can be removed only by these poses. The shift of the navel to the centre can easily be observed over weeks of training. Occasionally, it may take a patient longer than two to three months for restoration of a normal spinal position. Rest assured this always happens, unlike in medical science where one is always worried by the presence of the tilt. Persistence of the tilt, with conservative management, is often considered a sign of poor recovery but with yoga this fear need never occur. These lateral bending asanas also have a rotational component — outwards to open the chest — but the main emphasis is on lateral extension. The length of the spinal muscles and ligaments is increased as the poses act like traction. Hence relief occurs, as the congested area is provided space. Lateral bending and rotational asanas like Ardha Chandrasana and its cycle provide excellent relief. Ardha Chandrasana has both concave and convex movements to offer. Initially, the concave version is highly useful for the soreness of the muscles. It also increases inter-discal space, thus decompressing the affected area. Lateral bends are the only means to remove the asymmetrical tilt of the spine. In no other science is this method available. Rotational poses like Parivrtta Trikonasana and Parivrtta Parsvakonasana on the horse, standing Marichyasana and seated Bharadwajasana near the wall are very effective in posteriolateral prolapse. Pure posterior prolapses are treated by all these asanas as well as by Dog pose, Marichyasana, and Bharadvajasana. Uttanasana involves flexion but is done by hanging and stretching the body downward on the horse, known as ‘hanging Uttanasana’ (see illustration) with the help of the horse prop, so that the strain on the back is reduced and the patient can regain forward movement. The advantage of this pose is that gravity acts on the spinal muscles and relief occurs at once. In seated or standing forward bends, one has to pull the spinal muscles and this can strain the patient. Moreover, in the hanging position, automatic alignment of both sides of the spinal muscles occurs as the tractional forces work.

Supta Padangusthasana with rope. The side pose (right) is highly specific for relieving sciatic pain by stretching the piriformis muscle, while the front pose (left) relieves backaches.

Hasta Padangusthasana with footrest elasticises hamstring and spinal muscles simultaneously and relieves sciatic pain.

Using the horse prop with four poses: Trikonasana (above left) and Parsvakonasana (above right) ensure accuracy, fast pain relief, disc realignment and supple muscles; Parivrtta Parsvakonasana (below left) provides longer range of rotation for excellent pain relief and disc realignment; Ardha Chandrasana (below right) relieves sciatica. The concave nature of the spine relieves backache quickly.

Inverted forward bends like half Halasana are very useful to help the patient to start flexing the spine. Done on the stool, the spine does not suffer strain. Unless the patient develops complete flexibility in standing and seated forward bends, the problem can recur. Eventually, complete flexibility in all standing forward bends should be achieved. Seated bends are to be practised after very good improvement has occurred with all of the above poses. Modifications are needed. For example, to practise Paschimottanasana, the patient has to sit on a high chair with the legs on the floor and bend forward. This does not harm the spine as the muscles are lengthened in the process. It is only in forward bends that maximum lengthening of the spinal muscles occurs due to the geometry of the pose. The calculated stretching of the posterior intervertebral joints gives relief from pain as pressure on the disc is reduced and the spasm of the nerves, muscles and ligaments released. It also improves blood supply to the injured area and allows better healing. Vascular edema is diminished due to the space created by the forward stretch. The muscles and the ligaments become soft and elastic, improving ligament and muscle tone. This prevents recurrent problems and future prolapse at a different level. Most patients with a disc problem have extremely stiff spinal and hamstring muscles. Attending to this is more important than merely removing the disc. Western medicine has little knowledge of the functional movements of yoga.

Dog pose provides enormous relief from pain. It is one of the finest poses for a low back disorder. Done with the rope, it gives traction in a controlled manner. Traction in yoga is a controlled conscious process. One can increase or decrease the amount of traction at different parts of the spinal column by feeling the alignment of the joints and the spinal muscles. All the above-mentioned asanas provide relief from pain in both the lumbar and sacroiliac regions. Once the patient is able to practice these poses independent of the props, the problem is vanquished. It must be understood, of course, that once the anulus ruptures no procedure can seal the rent again, nor is it necessary. One can live with the disc outside its normal plane provided the disc does not impinge on the nerve roots. The disc is a mobile structure after rupture. This movement is provided for by our spinal muscles, as we bend or stretch which, in turn, pushes the disc. If the body movements are not flexible or harmonious in different directions, the disc can be forced into the nerve root due to tight jerky movements of the spinal and hamstring muscles. This causes further pain as the nerve is pressed. So long as the patient remains flexible, the nerve root is not irritated and there is no cause for concern. The situation is like a caries tooth. We do not remove it because there is a cavity, unless there are other complications. Even with a root canal filling one can carry on normal activity. Thus the asanas prevent the disc from getting into contact with the nerve root. This is done by a variety of geometric shapes.

Dog pose with rope provides instant disc decompression, which is more accurate than medical traction, and faster pain relief.

If sciatic pain is the predominant problem, practice of Hasta and Supta Padangusthasana is very valuable, either on one’s own or assisted by a helper. In acute and subacute situations help may be essential. Supta Padangusthasana with a sideward movement of the leg is invaluable in relieving and abolishing sciatic pain. The movement may be done several times daily (before or after food) like ingesting a drug. The pose decompresses the sciatic nerve at the exit point in the buttock. Relief is a pleasant sensation, better than a drug, as the piriformis is relaxed. Western medicine has no exercise for the piriformis problem. Extension (back bending) exercises are useful only for an anterior prolapse of the disc, which is very uncommon. If a person with a disc prolapse bends backwards, the movement produces pressure on the protruded disc increasing the pain, edema, vascular congestion and mechanical pressure. Bending backward causes narrowing of the spinal canal while stretching forward increases the canal space. This is obviously more beneficial. Once the condition is normalised, back bends can be practised in a modified form by the patient.

Uttanasana, the right and the wrong way. Figure on right shows a hunched up attempt in stretching to the floor. At left is the correct healthy stretch, originating from the sacro-iliac muscles. Stretching, not bending, is the correct method of spinal movement. In Western medicine, spinal flexion is erroneously avoided.

Concave movements of the spine are good for disc prolapse as the movements soothe the sore muscles. If, in the process of aligning the spine in the concave position, the relevant muscles tend to contract rather than stretch (as in extension exercises like Salabhasana which are often prescribed), the spinal muscles suffer pain as the muscles are already in a state of spasm. If one stretches the spine forward or to the side, maintaining the concavity of the spine, injury does not occur (see illustration of Trikonasana on prop). Most people have a hunch in the lumbar region when they bend forward. This means that the lower spinal (sacroiliac) muscles are very stiff and one has to learn how to stretch this area. It is important to understand that it is forward stretching — not bending — that is beneficial. A forward bend can snap the spinal muscles as the geometry of such a movement places stress on the intervertebral joints and the disc (see illustration of right and wrong bending in Uttanasana). Rest for the muscles is useful only in acute conditions. Excessive rest becomes counter-productive as it stiffens the body, hampering proper blood circulation in the spinal muscles and hindering free movement and recovery. In the early stages of rehabilitation the pain can increase as the muscles are under spasm. If practice is persisted with, the tissues loosen up and the patient obtains relief. It is important to learn the nature of ‘right’ and ‘wrong’ pain. Pain is not necessarily unhealthy nor is it to be ignored. Stretching a healthy muscle does produce pain and soreness for a few hours or days. With practice, the muscles loosen up. If the muscles are already in a state of spasm, as in a case of spinal pathology,

any kind of movement will produce pain. But if this is along anatomical tenets, the pain will disappear. To decide whether this back pain is healthy or of a pathological nature requires the guidance of a medical professional. The pain decreases in a few days if the right method of movement is applied. Exercise-induced muscle soreness is a specific clinical entity of which the patient must be aware. Regular practice is essential and continuance is a must to maintain the healthy condition of the spine. With age, the body inevitably degenerates and hence exercises should not be discontinued. Care of the back is as essential as care of the teeth, as long as we live. If surgery has failed (failed back syndrome) rehabilitation is difficult. Nevertheless, it is possible to provide relief in select cases as yoga can help such patients too. But as the anatomical architecture and continuity is altered and disturbed by surgery, and adhesions (where the tissues stick to each other) may have formed, relief may take longer than normal. Asanas used to treat disc prolapse include Hasta Padangusthasana and its cycle; Trikonasana and its cycle; Parsvakonasana and cycle; Adho Mukha Svanasana; Uttanasana with support; Marichyasana and its cycle; Ardha Chandrasana and its cycle; and Supta Padangusthasana and its cycle. The classical asanas, however, have to be modified to suit the patients. Props are necessary. Later they can be dispensed with. Some of the asanas with props are illustrated here.

Fig 188 Spondylolisthesis (left) is the forward shift of one vertebra over another; the dotted lines show the correct alignment (right).

Spondylolisthesis of the lumbar spine This is a very common condition where the pars interarticularis of the vertebral body is broken, either because of a congenital defect or due to a stress fracture or a degenerative condition. The incidence in white skeletons, for example, is 4.2% in 2300 skeletons (Roche and Rowe 1951). This is yet another condition where surgery can be avoided if yoga is started early enough. But before we can proceed further we must understand the pathology of the condition.

Etiopathology The forward displacement (towards the front side of the body) of one vertebra over the other is known as spondylolisthesis (fig 188). This is due to lysis of the pars articularis as mentioned above. The lysis is more common at the L5 level over the S1 junction (though a slip of L4 over L5 vertebra can also occur) as this is a critical junction of the spinal column. The lysis may be at both sides or at one. The lysis may occur without any forward displacement and with no symptoms throughout life, only to be discovered during a routine examination, a master health check up. More commonly, a problem of backache occurs. The displacement and its progression is a gradual phenomenon. Obesity and a pendulous abdomen are potent aggravating factors that tend to drag the spine in the forward direction. It is common to notice the effect of this in a pregnant woman who, because of the extra load, has a hyperarched spine. In pace bowlers, due to the strong rotational forces on the spine acting with momentum, the pars can crack. A childhood fall on the back may be a forgotten cause. Gymnasts can suffer such injuries. Many occupational injuries can occur. In factories where persons have to load heavy objects onto

another area — such as lifting a lorry tyre hub to a higher level, which can be as frequent as loading 50 to 100 such hubs per day per person — stress fractures can occur.

Symptoms The most common symptom is low back pain. The symptoms can date from early life — from childhood, teenage or young adulthood. The patient can suffer from pressure on the lumbar nerve root and suffer sciatica or inability to walk for some distance: claudication pain. The terminal part of the spinal cord can be caught in the displaced angle and the patient can suffer an acute inability to move the legs. In severe cases the nerves innervating the bladder can be pressurised leading to difficulty in micturition. This is a situation which needs immediate surgery. It may be possible that more women than men suffer symptoms. The reason could be the softening effect on the ligaments of the spine by the hormonal changes of pregnancy.

Diagnosis The history of a fall is a pointer to the diagnosis. Physical examination of the patient in the early stages may reveal a mobile spine due to the excess mobility at the L5 junction. Thus a patient may, in spite of the pathology, flex the spine and touch the hands to the floor which a healthy person may not be able to do. Of course, in a situation of acute pain this is not possible. An excess of the lumbar arch producing an exaggerated hollow in the low back is a common finding. Tenderness on pressure in the affected area may occur. Pain and features of a low back pain problem is often present. In severe cases of a slip, a ridge or a groove on the patient’s back due to the slipping of the spine forward is often palpable. A good radiograph often helps in clinching the diagnosis. The break in continuity can be easily observed. A CT scan or an MRI provides a very clear picture. Severe cases will need surgery.

Medical management As mentioned before, patients can be symptomless for many years. If the defect is discovered on a routine examination, the most common dilemma is whether it warrants treatment. Definitely, surgical management is not the consideration at this juncture; but the patient should be instructed to keep the back healthy with exercises. In a patient with acute pain, rest and analgesics will serve the purpose. After recovery, the back can be strengthened with exercises. The recovery time may vary from patient to patient. The younger the patient, the better the overall prognosis. If recovery does not occur at all, which is uncommon, surgery may be considered. Before all this, it is essential to understand the logic of a listhetic spine according to yoga. The forward slip is due to tractional muscular forces working excessively in the said direction and the spine succumbs as the pars is already in discontinuity. If this force is opposed and the muscular forces push the spine in the backward direction (i.e., towards the back of the body), spinal stability can be achieved which is the aim of surgery too (apart from relief of symptoms). Hence the logic being one of devising mechanical forces to work on the spine, yoga is a foremost tool.

Yogic management In medicine, the exercises prescribed are not logical. They do nothing to achieve stability of the spine. Moreover, irrationally, forward bending is prohibited for listhetic patients. Ironically, it is a good forward stretch, not a bend, that works to push the spine in the backward direction for stability. A forward bend is harmful to the spine, a stretch is not. Even though a listhetic patient may naturally achieve a forward stretch without training, unless proper training in the techniques is given, the capacity is of no use. Moving forward of the muscular forces which increase the listhesis is along the line of the natural gravitational pull. Backward movement of the spinal muscles constitutes an ‘antigravity’ action which prevents slippage of the spine forward. This backward movement is available in all forward stretches done standing or seated. In forward stretches, the lumbosacral region is pushed upward and backward. This can be felt as one performs the pose. All standing poses are good for the listhetic patient as the upward lift of the spinal muscles serve to provide a vertical pull of the spine (in the direction of the head) and this capacity when used every day prevents downward and forward slippage of the spine. Uttanasana, Prasarita Padottanasana, Parsva Uttanasana. Props may be used. Pain is relieved rapidly. In the seated poses, all poses are invaluable, particularly Kurmasana. Poses like Urdhva Mukha Paschimottanasana, Ubhaya Padangusthasana and Krounchasana are very helpful to reverse the spinal curve. Practising Paschimottanasana from the wall ropes is very beneficial for the patient. Without strain, the spine is pushed back to position. This method is excellent for listhetic problems. The Eka Pada Sirsasana cycle is also useful. As the lumbar lordosis (the natural lumbar curve) is increased in these patients, constant practice of convex movements along with forward stretches reverses the curve. Excellent anti-gravity strength is obtained. Whatever angle of slippage the patient has when yoga is instituted, this can be maintained throughout life without aggravation. With intense practice, even a reversal is possible. Twice daily practice is a must for some time. As the spinal muscles are made convex in forward stretches, the benefits are immediate. Shoulder stand is very helpful as the spinal muscles are made convex and there is an upward stretch of the body. Seated twists which make the spinal muscles convex, like Ardha Matsyendrasana, Marichyasana, are valuable to relieve pain. Inversions can be safely practised. Balancing poses are invaluable due to the compressive forces which make the spinal muscles convex. Initially, backward bends are taboo for the listhetic patient as the lumbosacral angle is increased by these asanas and, as the patient already has a listhesis, the slip can be aggravated. After years of practising forward stretches, back bends can be learnt under skilled supervision. Again, a back bend is not really a bend, but a stretch. It can be performed without increasing the lumbar curve. Careful selection of the patient for surgery is important. Stages 3 and 4 will require fusion. Impending pressure on the nerves supplying the bladder and bowel will require surgery, but this does not happen in the majority of cases. Manifestations such as low back pain, nerve root entrapment, sciatic pain and claudication pain can easily be managed conservatively using yoga, as the asanas not only decompress the spinal nerves and strengthen the muscles, but physically move the forces that push the spine in the healthier direction. Surgery is done by fusing the spine in the place with nails. The pain does lessen but the quality of life

after surgery is more important. The patient has to sacrifice good mobility for pain relief. Whereas, if exercises are practised, both pain relief and healthier mobility results. After surgery it is still possible to exercise the spine. The patient has to be sensitive to learn the methods of forward stretches and subtly push the spine backwards. A crude force will achieve little. Scoliosis This means a lateral deformity of the spine. But it is always combined with a rotational component and hence it is incorrect to call it a purely lateral problem. The structural change may be permanent if not attended to at once. There are five main types of scoliosis: Infantile type This apparently has no cause, has a curve convex to the left and can be of a progressive nature. Idiopathic type The most important, it begins in childhood or adolescence and tends to increase progressively till young adulthood. The cause is unknown. Any part of the thoraco-lumbar spine may be affected. The lateral bend of the spine is accompanied by a rotational deformity of the vertebra on the vertical axis. This produces a characteristic deformity of the spine, more obvious when the patient bends forward. The symptoms are minimal, except for a cosmetic deformity, as pain occurs only as the muscles stiffen over the years. The medical treatment includes surgical methods and braces of various types, most of which can be avoided if the patient is seen early enough and yoga is introduced. Secondary structural scoliosis This has specific causes: congenital abnormalities of the vertebra, polio and a disease known as neurofibromatosis. Deformity is the only symptom and age of onset varies. Treatment is as for idiopathic scoliosis. Compensatory scoliosis If the legs are uneven in length the patient has to tilt to one side, producing an artificial scoliosis. If the hip joint is broken and shortened there is a compensatory tilt and so on. If the cause is treated, the tilt disappears. Sciatic scoliosis This is due to the irritation of the protruding disc on the emerging spinal nerves which tilts the spine to the side opposite to that of the prolapse; if the disc prolapses on the left the person tilts to the right, to avoid pressing the disc on the same side which might cause nerve pressure. The symptoms are pain

and a visible deformity which is a sudden occurrence. The deformity disappears once the acute condition abates. The treatment of a disc prolapse has already been discussed.

Medical management Medicine has no rational method to deal with scoliosis except by surgery. This is one disorder where surgery is better avoided except under certain constraints. Even if surgery is performed the reversal is not satisfactory. Yoga achieves better results in moulding the spine. Post-surgically, movements are more restricted than before as fixation occurs. When it is possible to reverse the curve non-surgically and, more important, definitely prevent progression, what is the need for surgery? Regularity of practice is a must. Cosmetic reasons justify surgery.

Fig 189 Scoliosis with convexity to the right. Arrows denote the direction of asana practice, for lateral bends only.

Yogic management Yoga is one method that works in arresting and reversing scoliosis excellently. The postures themselves produce a ‘physiological scoliosis’ when one practises them. The word physiological means something that is a natural outcome of a certain natural cause and the situation reverts back to normalcy once the causative factor stops operating. A common example is redness of face which occurs as a healthy flush after a bout of jogging. This reverses naturally and needs no interference. The same redness may be produced by a drug and this can have a damaging effect. Another example is that of elevation of blood pressure as a healthy person exercises, which returns to normalcy soon after. One cannot say that this healthy rise is damaging as it is a natural change in response to exercise. Whereas, in a hypertensive patient this return may be hampered for various reasons and one has to be more cautious when exercising. A pathological effect may or may not be reversible and the cause has to be quickly treated. In the former case, no treatment is needed. As the postures themselves have a variety of geometrical shapes, excellent results can be obtained by practising them. Except back bends and balancings, all asanas are invaluable. Standing poses like Trikonasana, Parsvakonasana and their variations are very useful. They serve to tilt the body to the opposite side of the scoliosis. For example, if the patient has a scoliosis with the convexity to the right, which means the spine is actually bent to the left side, only right-sided lateral bends have to be

done for a period of time to reverse the curve (fig 189). The scoliotic curve appears as though the person is bending to the left, in effect doing a Trikonasana to the left side. The forces to reverse this have to be to the opposite side. Dog pose is very useful to secure right alignment for scoliosis at any part of the spine. Ardha Chandrasana is invaluable, particularly with the horse prop. Parivrtta Ardha Chandrasana is equally necessary as it is a very difficult variation and, when done with the horse prop, is of great help in reversing the spinal curve. When the asanas are practised, the person has to be very attentive to minute details of adjustment to reverse the curve. Both the front and back of the body have to be watched to get the right geometry of the asana and the correct reversal. Initially, there will be pain in the affected area as one tries to reverse the curve. But later the practice becomes easier and relief occurs. For many months the person should practise one-sided bends and rotations (as the rotational deformity is also one-sided). The patient will find one side of the asana easy to execute and the other very stiff. It is the stiffer side that has to be made flexible and once this is done, the person should practise asanas on both sides. Apart from lateral bends and rotational poses in the standing category, forward bends both sitting and standing are invaluable. Imagine a wire that is bent and twisted. Detwisting alone is not enough, lengthening the wire is needed. Our spine is like a wire with many joints. Forward stretches lengthen the spine. Props may be used. Hanging forward bends on the wall are quick in their effect. This lengthening effect is more pronounced in forward bends than in side bends or rotations, where also the spine has to be stretched before the actual pose is performed. Janu Sirsasana is more valuable than other forward bends as the spine has to be rotated before the forward stretch is performed. Parivrtta Janu Sirsasana, especially with assistance, is an excellent remedy for scoliosis. It is not a temporary correction which occurs by yoga but, as the exercises are to be practised as a regular routine, correction is permanent. Pain is relieved rapidly in idiopathic scoliosis. In two to six months the curvature can be reversed, unless the deformity is severe and the spine is frozen. This does not happen if the disease is identified early and the patient starts practising yoga. Assistance by another person as one practises the poses is very helpful for quick effect. The horse prop is invaluable. Once the necessary effect has been obtained the patient can also practise back bends. Head stand is helpful as gravity helps lengthen the spinal muscles. Variations of Shoulder stand, such as Parsva Sarvangasana and Parsva Padmasana in Sarvangasana, help correct lateral deformities. Except for secondary scoliosis and compensatory types, all others can be successfully managed by yoga alone. Even if the patient has no pain at the time of diagnosis, therapy should start.

Arthritis From the Greek era, the term ‘arthritis’ has been used for diseases of joints. It includes inflammatory and degenerative conditions affecting joints. Clinically, arthritis is characterised by pain and difficulty of movement at a joint. I will discuss three common types: osteoarthritis, gouty arthritis and rheumatoid arthritis.

Osteoarthritis Osteoarthritis is a degenerative disorder where the joint surfaces lose their spatial relationship with

each other and the articular surfaces of the bones rub against each other. Inflammation occurs and excess synovial fluid is secreted. Reduction of movement, pain and stiffness occur. Gradually, due to repeated inflammation, the joint becomes fused and mobility is impossible. The pain now is almost nil and the joint is ‘dead’.

Causative factors In Western medicine, the cause of this disorder is not entirely known; it is thought to be a natural degenerative one that occurs with the aging process of the body or a metabolically active disorder. Hence, it is often accepted as inevitable. Any kind of trauma, injury or infection causes premature osteoarthritic change in the joints. Sports and other events, which induce a lot of wear in the joints, and cartilage tears waste the muscles prematurely. Obesity is an important pre-disposing factor. The age at which osteoarthritis usually occurs is 55 to 65 years. These days, because of unhealthy lifestyles, this is seen in younger age group (30 to 40 years). Yoga has clearly stated that, apart from predisposing causes, uneven usage of joints in daily life and non-maintenance of suppleness are core reasons. That is why persons who practise yoga never develop arthritis if the practice has been technically precise. Osteoarthritis of the hip joint, for example, can be caused by damage to the head of the femur due to drugs (steroids being notorious for causing this condition) and damage to the blood supply of the head of the femur (Perthe’s disease). Frozen shoulder or periarthritis (peri means around and in this condition the ligaments and muscles around the joint are affected) is common particularly in diabetics where the tissues of the shoulder become stickier than normal. Persons who use one limb more than the other suffer premature wear and tear. If a person sleeps with the body weight on one shoulder every night, that side will suffer periarthritis due to jamming of the ball of the shoulder into the socket and constriction of muscles.

Symptoms In the knee I have dealt with this joint first as this is the most common site of affliction. The patient suffers pain, insidious in onset, aggravated by movement and relieved by rest. Gradually the pain becomes continuous and confined to a particular part of the knee. Weight-bearing, as in climbing up or down the stairs, becomes difficult. Rapid progression of symptoms is more common in the obese due to the excess weight borne by the joint. If there is a history of injury, the symptoms progress rapidly. Normally, the weight from the upper part of the body is transmitted to the hip joint and, in a straight line through the centre of the knee, to the heel and then to the fore foot. If the leg is bowed or the person has a ‘knock knee’, the weight distribution follows a different pathway which is unnatural. The knee joint is not built for such altered transmission of weight. Over the years, the pain progresses and the patient is forced to restrict all movement save minor ones. This in itself produces further pain due to disuse atrophy of the muscles and ligaments and poor blood circulation. Clinically, the joint suffers loss of flexion and extension. It becomes shaky, and the muscles appear

wasted. Examination reveals a cracking sound in the knee due to poor secretion of fluid that normally lubricates the joint, and friction due to reduced space between the tibia and femur. The knee might appear swollen (with a reddish skin on the affected area) due to the constant friction with effusion of synovial fluid. The synovial lining might be thickened in chronic cases. The radiograph may reveal narrowing of the joint space and bony degeneration with osteophyte formation. These are bony spurs that are formed due to friction. It represents a degenerative change. In the hip joint As the hip is a weight-bearing joint, the patient experiences pain in the groin, in the outer side of the hip, referred pain in the knee, inability to walk for long (and later, short) distances on level ground. Climbing stairs becomes gradually impossible. Movement gets so difficult that the patient avoids it, leading to a vicious cycle of greater stiffness due to lack of movement. This further reduces blood circulation in the joint, muscles and ligaments, and aggravates the symptoms. The patient also finds it difficult to sit cross-legged on the floor. As the disease progresses, the joint becomes stuck and limitation of all movement takes place. In the shoulder joint As regards the shoulder joint, the patient notices a stiffness in certain movements: elevation of the arm in front, and the act of taking the hand to the shoulder blades (as in soaping the back). Gradually the intermittent pain becomes continuous and results in gross limitation of all shoulder movements. Pain also lessens as the nerves transmitting pain get damaged, and the joint is ‘dead’. Radiographs in both these joints may reveal narrowing of joint space and damage of joint architecture. If the patient is a woman in the menopausal age group, presence of osteoporosis will add to the arthritic pain. The ankle, wrist and fingers joints The inner side of the ankle is easily affected as the shape of the area predisposes it to the condition. The patient suffers pain while walking short distances on level ground. The pain is relieved by rest initially and is later continuous. On examination, the area is swollen and tender, the movements limited and the skin red. In the wrist, the problem is usually a sequel to an old injury. Pain and limitation of movement are the symptoms. In the fingers, the patient complains of pain in the metacarpal and the interphalangeal joints. The joint at the base of the thumb is a common site of affliction. A tender swelling may be noted in the affected areas.

Medical management Management of these problems consists of analgesics to relieve pain and inflammation, resting the joint for a short period, and physiotherapy. Most patients continue to have recurrent episodes. Drugs are often ill-tolerated in the long run. Patients do not get adequate relief unless exercises are

introduced. The root of the matter is that the joint space has to be re-established. This gives strength, reduces inflammation and arrests wear and tear of the joint. Asanas can provide intra-articular massage for all joints and improve blood flow, wash away products of inflammation, allowing fresh blood into the areas for healing processes. Physiotherapeutic movements are technically unsound as they are dynamic in nature and can result in pain. As the movements are not steady and soothing, there is no time for the kind of chemical and biomechanical changes produced by asanas. The range of movement available in physiotherapy is limited in comparison to yoga. Surgery is valuable in select cases and greatly improves quality of life.

Yogic management Yoga can pull the joint surfaces apart by various asanas. This is far more rational in approach. In contrast to the solely extension exercises prescribed for the joints, both extension and flexion movements are given in yoga to thin down the synovial membrane and give rest to the joint. In the knee, for example, it is more important to increase the joint space than merely strengthen the quadriceps. In yoga, the method of toning up the power of this muscle is different. The load given to the muscles is static and not dynamic. This produces better pain relief. Dynamic methods waste the joint surfaces (except cycling). Asanas provide traction during movement, to increase the joint space (this concept of traction to the joints is not known to conventional medicine). In due time, the pain disappears and the joint is healthy again. If the joints have already fused when the patient starts yoga, nothing much can be achieved except a joint replacement. The earlier the use of yoga in osteoarthritis, the better the result. Once a certain flexibility is achieved, the patient can practise all possible asanas.

Arthritic knees Many people do not walk straight but turn the knee outward during walking. This results in a greater load on the medial ligament in the inner side of the knee. After years of wrong weight-bearing, the medial (inner) part of the ligament and cartilage wears away. In some patients, there occurs a burning sensation in the area of the medial ligament. The entire leg can assume a bow shape, resulting in loss of mechanical efficiency. This causes an altered stress distribution pattern on other joints in the body, leading to secondary problems. The spine is the most vulnerable in this regard. As the cartilages are avascular structures, it is not possible to rebuild them. A common problem is that of alignment. In osteoarthritis of the knee, the joint is affected primarily due to wrong muscular forces acting on the leg. The bones themselves are moved only by the muscles, and the altered pull of the muscles causes wear and tear of the cartilage in the knee. This altered pull, as mentioned before, is due to wrong positioning and usage. For example, many housewives, as they stand before the kitchen counter, turn their knees outward. Depending on which knee is favoured in this process, degeneration begins in that joint.

The stress of the muscles actually changes the shape of the bone. The bones also suffer poor mineral content if used improperly or ineffectively. In yoga, a belt is tied around the middle of the shin bones and retained for a certain period. This acts like a brace does on the teeth, by pushing the bones to the centre, preventing further worsening of the curvature. Therefore, if one understands the proper way to walk, sit, stand, etc., using the muscles evenly, this problem is easily avoided. The same principle applies to the hip joint.

Virasana in four positions: standing; kneeling; prone, or Bhekasana; and sitting, with pillow. All four positions are important in the treatment of arthritis of the knee as they provide pain relief and flexibility, remove effusion (swelling of knee) and stop further degeneration. The cloth inserted at the knee prevents crushing of the internal ligaments of the joint.

Obese patients, having greater load on the joints, are easily prone to premature joint wastage. Unless the excess weight is shed, complete relief cannot be obtained. Initially, the knee may become more painful. This is due to exercise-induced muscle soreness which usually disappears in a few days. Synovial thickening takes a long time to reduce. Once the joint recovers, the recurrence rate is very low, provided the exercises are regularly practised. A word must be said about the technique of manipulation. The patient is under general anaesthesia, and the frozen joint is made flexible with force. This helps some patients. In many, the pain becomes worse. The technique has limited application. If a very difficult asana is achieved under general anaesthesia, when the normal practice would take several months, the body will become inflamed and sore in the next few days. This technique should be used only in exceptional cases. If the patient can bear pain, the steady daily stretch of the joint will yield sure results. Patients who cannot bear pain take a long time to recover. The asanas which help osteoarthritis of the knee joint include standing Virasana, kneeling Virasana, Bhekasana, Padmasana, Virasana and standing poses with the foot rest.

In the Virasana cycle, the cartilages are toned up, alignment given, and flexibility regained. This relieves pain. In standing Virasana, in comparison to the kneeling kind, the strain on the quadriceps progressively increases, thus toning the joint. Bhekasana is one of the key postures in which maximum elasticity is given to the joint. In virasana the knee is flexed fully, using a pillow to avoid strain to the ligaments inside the knee, toning up the cruciate ligaments which are located deep inside the joint. This is important for joint stability. Limited weight-bearing is introduced in this pose. If the person is not able to perform the Virasana cycle, manual help is given with traction applied to the knee (see illustration of prone position, page 456). Blood circulation in the knee is improved by the virasana cycle. The cartilages are massaged and pain is relieved. Due to free movement being attained, inflammation and pain are reduced. In standing poses with the footrest, maximum health is given to the joint cartilages, ligaments and muscles. This is in terms of flexibility, weight-bearing and power build-up. The bones and joints, being able to cope with a greater load, start functioning better. Some asanas create a medial pull on the bones, thus relieving the altered stress on the cartilages. In early cases, therefore, it might be possible to change the bony alignment. In the Trikonasana cycle the foot rest is used and the foot is dorsiflexed against it. This strengthens the cartilages and also avoids irritation when the pose is performed. For practising the Parsvakonasana cycle, the foot is kept slightly below and for Parsvottanasana the foot is dorsiflexed. All this has to be learnt under professional guidance. Virabadhrasana I is very helpful when two belts are used around the knee joint and the knee braced backwards by pulling on the belt. Prasarita Padottanasana is useful to tone the medial part of the cartilages. For medial ligament pain, the use of a belt above the knee and applying a medio-lateral pull on the ligament, while in Dandasana, abolishes the pain by repositioning the ligament. Padmasana, where flexion is combined with external rotation, is very good to tone the ligaments of the knee and the cartilages. It is this combination of multiple actions in a single movement that is the beauty of the science of yoga.

Hasta Padangusthasana is a basic pose for strengthening the knee and serves as a prelude to the other poses on the footrest.

Trikonasana (above) with heel pushed into footrest and Virabadhrasana II (below) with footrest. In the former, the heel positioning strengthens the knee cartilages, improves circulation and relieves pain. In the latter, the right-angled position of the leg strengthens the quadraceps and cartilages, improving the capacity to ascend and descend stairs. In both asanas, the stretched out leg with an added rotation on the knee cap strengthens the cartilages, preventing sudden buckling.

Padmasana also works by intra-articular massage. This and virasana are among the finest poses for joint massage. This action is not available in other poses. Arthritic hips and ankles The rationale of treatment is similar in osteoarthritis of the hip and shoulder joints. As the hip is a weight-bearing joint, recovery takes a longer time than the shoulder joint. The asanas that help arthritic hips and ankles are all standing poses: Supta Padangusthasana and its cycle, Baddha Konasana and Upavishta Konasana, Hanumanasana, Samakonasana, and twisting poses. Arthritic shoulders, wrists and fingers For osteoarthritis of the shoulder, the movements consist of total extension in such a manner that it opens the entire joint, yet avoids injury. This gives lightness to the joint, for the contracted and fibrosed muscles are released. Asanas like Tadasana, Hand stand, Elbow balance, Dog pose, Urdhva Dhanurasana, etc., give great relief by increasing the joint space and help in weight bearing. The other relevant asanas include all standing poses, inversions, forward and back bends, twisting poses and balancing poses. For an average person there are simpler movements like holding a bar behind the

back, the reverse namaste, strapping a belt on the arms behind the shoulder, interlocking the arms behind the back, Uttanasana with the hands stretched over the back, and so on (see illustrations on page 460). The shoulder is particularly prone to becoming frozen in diabetics due to altered synthesis of tissue components which are stickier. This condition responds very well to treatment.

Parsva Uttanasana, with heel pushed into footrest, makes for a different geometric shape but results in the same benefits as Trikonasana and Virabadhrasana.

For the wrist all the above asanas are helpful. For the fingers the special manipulation of the joints has to be learnt to provide total extension and flexion. Osteoarthritis is unknown to yogic science as the very basis of yoga is preservation of the mobility of the body. In yoga, the movements are done in a highly arithmetical and geometrical manner to avoid injury to joints.

Dandasana with belt for the knees is invaluable for arresting bowing of the knees and subsequent malalignment. It is excellent for pain relief.

Nervous and circulatory energies do not flow freely in an arthritic joint. Yoga restores health of the joints by promoting softness and suppleness. Other therapies like magnetotherapy and homeopathy cannot solve the problem except to relieve pain and inflammation. Yoga alone does the job of realigning joints.

Gouty arthritis Gouty arthritis is a metabolic disorder characterised by elevation in the blood level of uric acid and deposition of uric acid crystals in the joints. Purines are constituents of DNA and RNA, used by the body for nucleic acid synthesis. They may be derived from the diet or from broken-down nucleic acids. They may be reused for synthesis or converted to urate and excreted through the kidney (75%) or intestine (25%). Solubility of the chemical in the plasma is limited; precipitation in the tissue may be favoured by a variety of factors: pH, temperature, trauma, etc. Gout is rare in children and women of child-bearing age. A high meat diet can increase uric acid levels; so can alcohol.

Causative factors The cause of this disease may be: (i) decreased excretion of uric acid; (ii) increased production of uric acid; or (iii) both. Decreased renal excretion of uric acid may be due to one or more of these reasons: (a) chronic renal disease; (b) lead poisoning; (c) hypertension; (d) thyroid hypofunction; (e) a variety of drugs including salicylates like aspirin, anti-inflammatory drugs like phenylbutazone and anti-tuberculous

drugs; (f) increased levels of acids during exercise, starvation, alcohol consumption.

Five variations of Tadasana.

With arms over head, is a basic pose for pain relief, normalising frontal elevation of shoulders.

Holding window bar while standing straight, normalises posterior lifting of shoulder.

Squatting and holding window bar, provides complete posterial extension of shoulders.

With belt for shoulder results in instant pain relief and helps shoulder expansion. It is a prelude to taking the arm behind, as in soaping the back.

Reverse namaste provides full flexibility of posterior movement.

Uttanasana with arms holding bar above the head makes for complete overhead flexibility of shoulder.

Increased production of uric acid occurs in a variety of disorders: (a) blood malignancies; (b) psoriasis; (c) anaemia, where the RBCs are broken down; and (d) a deficiency of certain metabolic enzymes regulating uric synthesis. The cardinal manifestations are: (i) arthritis; (ii) tophaceous deposits; (iii) renal disease. Serum uric acid may be elevated but mere elevation is not sufficient to diagnose gout. Events like trauma, surgery, any systemic illness, alcohol, severe dieting and drugs precipitate gout. Associated renal disease accounts for 20% to 25% of deaths in gout.

Symptoms The joint of the big toe is most commonly affected. This happens suddenly, with severe pain and inflammation and redness of the overlying skin. The patient is woken up from sleep by pain. The attack is often very painful and subsides spontaneously. The other sites of affliction are, in order of frequency, the insteps, ankles, heels, knees, wrists, fingers and elbows. The age group usually afflicted is around 30 to 60 years and the male/female ratio is 8:1. It is uncommon in males before puberty. The axial skeleton is rarely affected. The attacks are single or recurrent; and repeated attacks damage the joint. There are periods of total absence of the disease — the inter-critical period. The phase of chronic tophaceous gout follows recurrent attacks and is characterised by asymmetrical joint swelling. The cartilage of the ear, bursae and tendon sheaths in the feet and hands are commonly affected. Associated renal damage is common.

Medical management The diagnosis is made by the finding of elevated uric acid at the time of an attack and the demonstration of uric acid crystals in synovial fluid from acutely inflamed joints using polarised light microscopy. Gout has to be differentiated from other disorders like rheumatoid arthritis, infectious arthritis, psoriatic arthritis and those associated with inflammatory bowel disorders such as colitis. Medical management of gout is directed against the causative factor. The acute attack is treated by oral anti-inflammatory drugs. Colchicine is the most frequently used drug. It is taken every two hours until the symptoms are relieved, or until side effects like diarrhoea occur. There are plenty of side effects to colchicine like alopecia (hair loss), mental depression, bone marrow depression. NSAIDS are also valuable as alternatives to colchicine. Once the acute attack is controlled, a programme must be evolved to prevent future attacks. The diet must be monitored. Excessive uric acid in the body may need to be removed by agents that provoke excretion. The most common in use are sulphinpyraznone and probenecid. These do not have any antiinflammatory action. Skin rash and gastro-intestinal side effects are common. Drugs that reduce the synthesis of uric acid are also used but only after the attack is controlled. All these measures are needed, but unless attention is paid to relief of the joint affliction and restoration of movement, the patient will never be symptomatically comfortable. This is important to prevent joint deformities.

Yogic management Provided no specific cause for the elevated uric acid is detected, yoga can be used for relieving joint pathology and other systemic manifestations. If the joints are well used, pain is reduced and cartilage damage is less in the long run. Yoga is ideal as the joints can be massaged in a methodical manner. In an acute attack, no exercise is to be done. When the patient isasymptomatic, with residual joint damage and restriction of mobility, therapy should begin. Even if the disease has reached the chronic phase, the asanas help dissolve the deposits of uric acid in the lining of the joint, provided the damage is within a certain degree. The process is painful at first due to stiffness, but eases after some time. Regular practice of asanas prevents deposition of material in the joint as well as cartilage damage. All the asanas are useful in this respect, especially to prevent systemic damage. Even though gout itself is a disease that is inactive from time to time, it is important to realise that when the next attack occurs, the joints again suffer. It is this problem that yoga prevents. Joints that are exercised well never suffer pain and damage. The entire repertoire of standing poses tones up the major joints so that they are totally spared the deposition. Virasana is greatly helpful in relieving pain in the foot and ankle joint, and prevents deposits on the big toe. Joint massage in yoga is unlike any other. All other types may actually aggravate the pain due to being ‘irritative’ to the joint. The steady action of improving the circulation and calculated precision in exercising the joint help wash away the deposits. The exercises in yoga can be passive or active, depending upon the need of the moment. Twisting poses, back bends and inversions are all needed to prevent organ damage. Regular practice prevents both systemic and joint manifestations of the disease. Of course, it is necessary that the inner

metabolic pathology be tackled according to the cause. Yoga also tones up the inner organs by helping to flush out the excess uric acid. It is no exaggeration to say that a practitioner of yoga never suffers from these disorders. Dietary manipulation is invaluable.

Rheumatoid arthritis A chronic inflammatory condition of all the joints with systemic manifestations often associated with constitutional symptoms, rheumatoid arthritis can affect both growing children and adults.

Causative factors The exact cause is unknown and the possibilities are genetic predisposition, auto-immune disorders and infection. The auto-immune supposition recognises the theory that the antibodies of our body are directed against the tissues of the body itself. Thus, it is a process of incorrect recognition: ‘self against self’. The infection theory remains to be proved. The female to male ratio is 4:1. Again the reason is unknown; it may be hormonal or stress related. Pathology of the joint manifestations The essential change is in the synovial lining which is inflamed and thickened. The chronic phase results in loss of underlying joint cartilage and bone due to invasion of the inflammatory process into the tissues. The tendon sheaths in the hands and the feet are thickened, resulting in limitation of movement. Extra-articular manifestations Inflammatory nodules may appear in the heart and lungs. They are also found in the hands and legs over the insertion of the tendons. The blood vessels of any organ may become inflamed. This can cause an infarct if the coronaries are affected. Inflammation of the heart muscle and lungs, pleuritis, shrinkage of the lungs (fibrosis), inflammation of the iris (iritis), enlargement of the spleen, muscle wastage and osteoporosis due to long-standing disease are some of the other manifestations. After years of inflammatory activity, joint architecture is destroyed causing permanent deformities of a characteristic manner. The nerves in the wrist can be affected causing carpal tunnel syndrome with numbness in the palm of a specific nature.

Symptoms The onset may be sudden or gradual. Progressive swelling of the joint brings the patient to the doctor. There is pain, limitation of movement and tenderness in the joint. The ligaments are often damaged and subluxation (malpositioning) of the joint may occur. The patient suffers early morning stiffness, pain, inability to move the affected joint freely, swollen joints, and a feeling of warmth in the joint. The disease process may be of a mild nature or, in particular cases, relentless and progressive. This is more often difficult to treat, as there is rapid deterioration of all systems, particularly the joint manifestations. The finger joints are characteristically involved though none of the joints are spared.

No test is diagnostic of this condition. The biochemical values are abnormal, particularly the erythrocyte sedimentation rate (ESR). This refers to the rate at which RBCs settle down in a test tube. The values are high in any pathological state. The disease may go into remission or enter the chronic phase with progressive symptoms. The rheumatoid factor is useful for prognosis. High values of this may indicate a severe downhill progression. A negative result, however, does not rule out the disease. Newer tests like anti-CCP are very valuable for diagnosis.

Medical management The mainstay of medical treatment is rest, relief of constitutional symptoms, and anti-inflammatory drugs. The anti-malarial drug chloroquine is useful to relieve symptoms. Drugs do their bit to alleviate joint manifestations in rheumatoid arthritis. Many patients come with progressive joint loss; if they had exercised their joints at the right stage, they would have fared better. Drugs do not normalise the ESR beyond a certain degree. In patients with severe symptoms drugs like gold injections, anti-cancer agents like methotrexate, etc., have provided relief. But the side effects — bone marrow depression, inflammation of the liver, etc — have to be carefully monitored. Intraarticular steroid injections are occasionally valuable to relieve pain. Approaching the disease practically, it is of paramount importance to preserve joint mobility and integrity so that the patient can continue everyday activities. This rarely happens without some form of exercise. Research has shown that joints are less affected if exercised regularly. Physiotherapy irritates the joint lining by repetitive movements. A steady stretch or contraction is more beneficial for joint health.

Yogic management According to yogic concepts, joints kept healthy in terms of blood circulation (which means good flexibility) will remain healthy. The logic by which yoga helps the joint is very straightforward. The massage to the joint helps increase blood circulation, drain away products of inflammation from the area, bring in fresh blood for healing. The swelling takes a long time to disappear, but the pain reduces earlier. The patient must be instructed to bear a lot of pain in the early stage of loosening the joints if they are initially very frozen. To help tide over the pain, analgesics are helpful. Once joint mobility improves, drugs can be discontinued. With regular practice, relapses seldom occur so far as joint manifestations are concerned. Of all the arthritic disorders, this is the most painful. However, results are sure and long lasting. Some of the movements are to be done several times a day to ensure fast relief. The normal ESR rate is around 4-8 mm per hour. In rheumatoid arthritis, it can be as high as 50 or 100. Joint pains are more when the ESR is elevated. Once yoga is begun the pain reduces and even if the ESR rises, the joints will not feel pain to that extent. The capacity of the patient to bear pain while exercising in the initial phase decides the end result. Improved haemodynamics of the joint prevent bone loss, heal the cartilage and help regrowth. Synovial thickening can also be reduced by regular practice. Aspiration of the joint is useful in some cases; but repeated procedures are not to be done, as this results in a negative suction effect, and fluid

forms in the joint again. All asanas are used to correct the problem. Standing poses are very useful in improving joint mechanics. The spine is greatly benefited. The virasana cycle improves circulation, relieves pain, and brings back resilience of the joint. The more the patient improves, the more the number of asanas that can be practised. Even though the ESR cannot be normalised easily, the patient can be saved from becoming a cripple which will definitely happen if exercises are not practised. The method of performing the exercises is very subtle and delicate. Initially, the help of other members of the family may be required. After a while, the patient can practise alone. Dietary changes are useful for treatment of rheumatoid arthritis. Except in some cases, there is no role for the use of intra-articular injections of steroids as their relief is temporary and they damage the joint in the long run. Surgery has its value in many cases. Joint replacement enhances quality of life. The asanas recommended for gouty and rheumatoid arthritis include standing poses, Head and Shoulder stand cycle, Virasana and its cycle, all sitting asanas and their cycles. Props may be needed. With patience and perseverance and motivation from the medical professional, the patient can be helped to live a life free of pain. The disease has been shown to be aggravated by psychological stress. Apart from this, mental refusal to accept the disease and overcome it has been shown to intensify symptoms and delay recovery.

Calcaneal spur Calcaneal spur is a common problem in all age groups, most common among the thirty and forty-yearolds. Though the condition is not a serious problem, the chronic pain is very annoying.

Causative factors The exact causative factor is not known for certain in the logistics of Western medicine. The actual reason is faulty usage of the foot and the rest of the body. The body weight is distributed unevenly to the affected foot. This often goes unnoticed for years. The constant pressure on the tissues of the sole leads to degeneration of the protective fat pad under the heel bone. The heel bone gets pressurised by the weight, and friction occurs. This leads to what is known as a spur formation on the surface of the bone.

Fig 190 Left: a normal heel bone (calcaneum); right: with spur.

This spur is a beak-like projection (fig 190), which causes pain when walking. It is similar to the situation when a small stone sometimes gets under the sole inside the shoe and we feel the pricking pain at once. In the same manner, the spur creates pain.

Symptoms The patient is usually middle-aged. The onset of pain is insidious. The person finds it increasingly difficult to place the afflicted foot on the ground and, hence, most of the body weight is on the other leg. The altered weight distribution is transferred to the knee of the overused leg. The classic symptom is the inability to put the foot on the ground as soon as the patient wakes up from bed in the morning. The first step is very painful. This is due to the fact that, when it is rested, the pad starts recuperating, behaving like an abraded area where crust forms. (If the crust forming spot is displaced, pain results.) Nevertheless, if continued to be used, the tissues adapt to the pain in the course of the day and become ‘numb’. As the spur is a relatively minor pathology, nothing happens even if one flogs the tissues by constant usage, except persistence of pain. The same cannot be said about a back disorder if pain exists. Ongoing usage of the back without toning results in much greater pain. On examination, the affected area looks tender and swollen, and the tissues thickened. It is sensitive to pressure and touch. The skin may be red or otherwise discoloured. The site of pain varies; in most patients the maximum site of pain is in the centre of the sole of the heel. In fact, this site carries excruciating pain. Other sites of pain are on the border of the heel on both sides. A radiograph may reveal a bony outgrowth of the heel bone, the spur. Pain may be present even without a spur. This means that the tissues are inflamed and the person eventually develops a spur. Observation of the sufferer’s footwear reveals that it is worn out more on the affected side as the body weight is always on that side. This is an useful clue.

Medical management Use of analgesics is the mainstay of treatment. If there is no response to painkillers, an injection of hydrocortisone at the spot of pain can relieve it, in some patients, it can also aggravate the pain. The use of a special slipper with in-built elevation to support the heel area is supposed to relieve the pain but most fail to get relief. Medicine fails to understand that the causative factor is altered

biomechanics of body posture and movement.

Yogic management Yoga primarily prevents formation of a calcaneal spur as it teaches perfect biomechanics of movement and posture. Standing poses teach the right method of usage of the foot. They massage the tissue and bone, and prevent formation of spurs. All standing poses are valuable. When a spur is present, the poses must be carefully practised, as the pain can increase if they are wrongly done. Hence, the use of the rest under the foot (see illustration in arthritic knees) to prevent improper weight transmission during practice. Gradually, the person can dispense with the foot rest. The poses massage the tissues of the foot, improve blood circulation and relieve pain by strengthening the ligaments and muscles of the arch of the foot.

Virasana with weight relieves pain through its massaging effect.

Inverted poses give relief from the congestion in the affected area. The part feels light as soon as the pose is done and the effect lasts for several hours. Weight bearing improves. The most beneficial asana for inflammation of the tissues on the sole, or a spur, is Virasana (illustration previous page). Because of the angle of the foot in the pose, this is the only pose that massages the foot in the geometrical manner needed. The arch is bent and the tissues soothed. Massage occurs without the need to actually touch the tissues of the foot. The relief perceived is almost immediate. The asana is to be done several times a day, before or after food, for five to ten

minutes. The pose is done by placing a weight on the heel and sitting on the weight which massages the heel. If a weight is not available, using a very firm cotton pillow will provide good relief. The moment one releases the pose and commences walking, weight bearing is easier. The relief lasts for a few hours. Continued practice several times a day relieves pain permanently. The spur will obviously remain (without increasing in size over the years), but the symptoms disappear.

Need for Extended Work with Therapeutic Yoga More work has to be done in the field of therapeutic yoga. If it is taken up systematically by medical professionals trained in Western medicine, the range of diseases that can be handled by a useful combination of the two can be greatly expanded. It is the duty of the doctor to cure the patient with the best means available. I have put forward certain notions about the mechanisms of yoga. What is a notion today can become a fact tomorrow or also a myth. We need to look into this with choiceless awareness.

Immunology and neurology Asanas are very useful in auto-immune disorders, like scleroderma, where the patient can be functionally normal due to the stretch given to the various parts of the body. The role of yoga in the management of cancer chemotherapy has been shown to be very useful. Some of the systemic side effects of chemotherapy like nausea, vomiting, loss of appetite and exhaustion can be treated by yoga. Yoga may completely prevent atherosclerotic Parkinson’s disease as the blood supply is maintained by inversions. But its role in treatment of the same is not a panacea. It is an adjunct to drug therapy. In Alzheimer’s disease, there is much scope for preventive yogic therapy. We advance the notion that regular practice of the Head stand from a young age may altogether prevent the formation of neurofibrillary tangles in risk groups. Long term studies are needed for this. Senile dementia due to diffuse cerebral atherosclerosis (DCA) can be totally prevented by regular practice of Head stand. Thrombotic or embolic strokes produced by atherosclerotic plaque can be completely prevented by Head stand. TIA rarely occurs in persons who practice Head stand regularly and correctly. In idiopathic epilepsy, the role of Sirsasana is very important as it stabilizes the neurons of the brain. The inhibiting effect of this pose on the spread of depolarization of the brain cells needs greater study and follow-up. The epileptic fit is supposedly provoked by the spreading of unsynchronized electrical waves. Asanas can reduce and prevent this change (not in all cases). Medication certainly can be lessened. The role of pranayama in this ailment needs study as the introversion of the senses can prevent recurrent attacks. The role of yoga in stabilizing and regulating the activity of the ascending reticular activating system in the brain stem (ARAS) and, therefore, its effect on sleep disorders is a very important area for study. Sleep apnoea syndrome, where the person goes into periods of spontaneous cessation of

breathing, can be abolished by regular practice of asanas. Snoring (unless due to an anatomical abnormality) can be stopped by yoga. Yoga is a palliative therapy for multiple sclerosis. In diseases like periodic paralysis (presumably due to alteration in potassium levels), asanas stabilize the nerve membrane and being static postures, do not cause fatigue. Later, the patient can exercise vigorously without strain. In post-Gullian Bare syndrome (a condition of possibly viral etiology which can cause sudden paralysis to the nerves of the body), asanas can be used in rehabilitation to bring the muscles back to normal along with weight training for wasted muscles.

Cardiology The role of yoga in valvular heart disease is interesting. The premature enlargement of the chambers and the onset of cardiac failure are delayed in patients who practice yoga. Surgery may be avoided in valvular heart disease, if yoga is started early enough. In primary pulmonary hypertension (PHT), if yoga is initiated early enough, premature failure of the right ventricle can be postponed by asanas which stretch the pulmonary tree and produce a fall in intra-pulmonary pressure. Elasticity is given to the pulmonary and micro vascular structures of the lung.

Respiratory diseases In chronic obstructive pulmonary disease (COPD), the role of yoga in alleviating the symptoms and preventing fresh bouts of congestion can be very useful. Spirometric assessment alone would be enough without the need for pre and post-bronchodilator assessment. The severity and frequency of infection as well as the long term use of antibiotics can certainly be minimized. The role of yoga in interstitial lung diseases (IF) should be explored. Dyspnea (breathlessness) could be controlled or, if diagnosed in the very early stages, the extent of fibrosis could be reduced. In infective disorders of the lungs, like bronchiectasis, yoga is most useful as postural drainage. It also prevents recurrent infections by providing fresh blood supply and better oxygenation to the lungs and allowing the T and B cells to circulate well.

Ophthalmology The part played by yoga, particularly Head stand, in the treatment of senile cataract needs very active study. As cataract is multifactorial in origin, yoga may have a role albeit not a major one. The role of Sirsasana in diabetic retinopathy is equally noteworthy. Regular practice of this asana can prevent capillary dilation, which is caused by hypoxia. The stimulus for new vessel formation may be profoundly affected by the Head stand and this needs careful study. Senile macular degeneration may be benefited by habitual inversion practice. This has to be researched. The fact that Head stand done correctly raises intra-ocular pressure (IOP) and yet does not cause damage in habitual yoga practitioners is very thought provoking (Intraocular Pressure Changes and Ocular Biometry during Sirsasana (Headstand Posture) in Yoga Practitioners - Opthalmology 2006; 113: 1327-1332).

Metabolic disorders It would be very useful to research the effect of yoga in preventing the micro vascular changes in diabetes. As the internal organs are massaged, interstitial changes could be avoided. Thus a long-term diabetic practicing yoga may altogether avoid suffering from nephropathy. As every nerve and blood vessel is stretched and toned, and its blood supply maintained, no pathological change occurs. In chronic gout, asanas break the uric acid crystals and prevent further joint damage. In cirrhosis of the liver (alcoholic or post-necrotic), further degeneration of the liver could be prevented by asanas as they stretch the organ and improve its blood supply. Due to the decompressive effects on the portal system, the portal venous pressure is kept low and rupture of the varices does not occur. There is no doubt that arthritis (except that caused by infection) can be completely prevented by yoga. It is unnecessary to develop better drugs for these problems as drugs do not increase the joint space whereas yoga does. Synovial fluid is resecreted by the practice of asanas. In idiopathic vertigo, asanas can bring about complete relief. Back bends are most useful for this. The development of fibroids in the uterine wall could be prevented by the practice of asanas, if started at a young age. Studies could be done on the effect of yoga on the rate of development of atherosclerosis as it has been repeatedly borne out by experience that it is greatly reduced or never happens in a yogic practitioner. It is becoming increasingly evident that medical disorders today cannot be tackled in their entirety with just a single system of therapy. Western medicine is becoming too compartmentalized into specialties. Medical professionals ought to expand their horizons and learn more about the intricacies of non-invasive therapies like yoga. Today’s situation is that, for most people, real health is lacking. Causes include ignorance leading to misdirected analysis of the situation and incorrect action, fear of disease as well as actual rise of diseases and escalating health care costs. The side effects of western medicine have also made people wary of this system of treatment. Focus in health care should be on preventive medicine through methods that are enduring, cost effective and without side effects. Health education programs should make people aware of the available options. What are the options in health care? They include western medicine, yoga, homeopathy, ayurveda and other alternative methods. If, for the moment, we focus on the relative advantages and disadvantages of western medicine and yoga, we find that the former is costly but quick, very useful in emergencies, highly advanced but causing many side effects. Yoga, on the other hand, is cost effective, can be quick or slow, has no side effects and is effective on a long term basis. As a practitioner trained in both methods, I strongly recommend that the best health care is obtained with regular practice of yoga combined with suitable changes in life style (relating to diet, avoidance of any form of addiction, regular sleep habits, etc). Recourse should be had to western medicine

when necessary, after careful thought and repeated consultation before taking any medication or undergoing surgical procedures. Consulting specialists trained in both sciences will ensure the best health care.

Appendix A quick reference to asanas and pranayama used for different organ systems in our body: This is a generalized list and many variations may be needed. All asanas have to be done under the guidance of a competent teacher. The duration needed for each asana varies. The capacity of each patient is an important factor to be considered. Props should be used if needed. The same rules apply for pranayama. The heart and lungs Supta Virasana with or without pillows - 357 Setu Bandha Sarvangasana on pillows - 46 Poorvottanasana - 374 Dog pose - 50 Head Stand on the ropes - 358 Viparita Dandasana on the chair or the rack - 357 Urdhva Dhanurasana on the ladder stool - 359 Shoulder stand on the chair - 358 Setu Bandha Sarvangasana on the little horse - 360 Viparita Karani on the pillows, against the wall - 65 Savasana - 367 Ujayyi pranayama, to begin with; followed later by all the different varieties, according to the individual’s capacity. The digestive system All the above asanas are invaluable. In addition: Marichyasana - 309 Ardha Matsyendrasana cycle - 309 Pasasana - 308 All forward bends are useful to stimulate the heat in the system and improve digestion Backbends prevent over functioning of the system Ujayyi pranayama to begin with; bastrika pranayama stimulates heat in the system and improves digestion; sitali cools the system and removes excess heat. The renal system All standing poses - 305, 306, 307 Inversions

Backbends are highly useful as they squeeze the kidney and massage it; all possible backbends, with or without props In summer, as the kidneys have to conserve water, sitali pranayama is valuable due to cooling effect; in winter, bastrika is useful. The hematopoietic system All asanas are valuable. Inversions are ‘nourishing’ to the system, a quality that none of the other poses have. Nadi shodana pranayama is the most useful as the prolonged inhalation, with kumbhaka and prolonged exhalation, optimizes the oxygen saturation of hemoglobin; this leads to increased energy levels and increased longevity of the cells due to excellent oxygenation. The endocrine system Head stand and shoulder stand - 306, 307 Forward bends, with or without support - 308, 396 Passive backbends - 337 When tired, supine pranayama with pillows is useful; otherwise, all varieties are important. The nervous system Head stand and shoulder stand - 306, 307 Forward bends - 396 Passive inversions like Viparita Karani and dog pose with ropes are helpful. - 65, 50 Nadi Shodana Pranayama is excellent to introvert the mind; kumbhakas and bandhas energise the system; short inhalations with prolonged exhalations are valuable for fatigue. Skin All asanas and pranayama are invaluable to maintain a supple elastic and soft skin texture as one grows older. The musculo-skeletal system Neck Hand and Elbow stand - 335 Head stand and shoulder stand - 306, 307 All back bends - 337 All forward bends - 396 All twisting asanas, standing or seated - 312 Eka Pada Sirsasana cycle - 311 Balancing poses - 310 Shoulders, arms and wrists

All standing poses - 296 Hand stand and elbow stand - 335 Chaturanga Dandasana Inversions Balancing poses - 310 Back bends - 337 Twisting asanas, seated - 312 Torso All asanas are valuable. Hip joint and knee All standing poses - 296 Supta Padangustasana - 308 Baddha and Upavishta Konasana - 308 Hanumanasana, Samakonasana - 312 Seated twisting poses - 312 Padmasana, Virasana cycle, - 104 Bhekasana - 456 Krounchasana, Mulabandhasana; Kandasana and Vamadevasana. Foot All standing poses - 296 Inversions Virasana cycle, Padmasana and Bhekasana - 104, 456 Baddha and Upavishta Konasana - 308 Mulabandasana and Kandasana Hanumanasana - 312 All backbends - 337

Glossary ACT H

adrenocorticotrophic hormone from the anterior pituitary, involved in various metabolic functions

ACUPUNCT URE

the science of manipulating various nerve centers in the body with fine needles

ADHO

facing down

AEROBIC

in the presence of oxygen

AKARNA

near the ear (karna = ear)

ALZHEIMER

a degenerative disease of the nervous system described by Alois Alzheimer in 1907

ANGINA

lack of blood flow and oxygen to an organ

ANGIOPLAST Y

a technique to open out blocked arteries

ANGUSTHA

toe

ANULUS

ring (annulus fibrosus: the cushion of tissue between the vertebral bodies, protecting the centre of the disc)

ARDHA

half

ART HRIT IS

inflammation of a joint

ASANA

posture

AT HERO

refers to blood vessel

AT P

adenosine triphosphate, a key chemical in cellular metabolism

AT ROPHY

wastage of tissue

AYUR

life

BADDHA

restrained

BAKA

crane

BHARADVAJA

name of a sage

BHEKA

frog

BHERUNDA

formidable

BHUJANGA

snake

CHANDRA

moon

CHEMOT HERAPY

drugs concerned with parasitic and living cells

CHOLEST EROL

a steroid in all living cells, needed for metabolic functions

CIRRHOSIS

from "kirrhos", meaning the colour yellow; refers to a disease where the liver is shrunken and destroyed

CLAUDICAT ION

pain in a working muscle due to lack of proper blood flow

CYST IC

pertaining to a sac filled with fluid

DANDA

staff or rod, symbol of authority

DEMENT IA

a condition of deterioration of intellectual function

DHANUR

bow

DISC

the cushion of jelly-like material between the vertebrae

DIURET IC

a chemical that depletes water and salt from the body

DYSMENORRHOEA

painful periods

DYSPNOEA

breathlessness

ECHOCARDIOGRAM

a technical means of determining cardiac function

ECT OPIC

out of place

EKA

one

EMPHYSEMA

a chronic lung disorder where the tissues are destroyed

FIBROIDS

benign tumor of the uterus

FRONTAL

in front of, front part of

GALAVA

age

GANDHA

cheek

GANGLION

a bundle of nerves

GLAUCOMA

condition of raised intraocular tension

GULLIAN BARE

a specific nerve disorder of unknown cause

HALA

plough

HATHA

ha = Sun; tha = Moon; union of sun and moon

HERNIA

prolapse of an organ

HOMEO

similar

HYPERAEMIA

excessive blood flow in an area

HYPERT ROPHY

increase in cell size and possibly cell number

HYPOXIA

lack of oxygen

INFARCT ION

death of tissue

INSOMNIA

sleeplessness

ISCHAEMIA

denotes lack of blood flow and oxygen to the heart

JANU

knee

KAPOTA

pigeon

KARANI

practice

KOUNDINYA

sname of a sage

KUKKUTA

cock

KYPHOSIS

convexity of the spine

LABYRINT H

a maze; anatomical structure in the ear

LAPLACE

name of a physiologist

LAT ERAL

away from the mid-line of the body, by the side of

LIPOMA

a collection of fat

LORDOSIS

concavity of the spine

LUMBAGO

a condition denoting spasm of spinal muscles

LYMPH

a tissue fluid

MANDALA

ring

MANIPURAKA

an important nerve plexus in the body, corresponding to the hypogastric plexus

MARICHA

name of a sage

MAT SYA

fish

MAYURA

peacock

MEDIAL

near the midline of the body

MENIERE’S DISEASE

symptoms of vertigo, deafness, etc

MENOPAUSE

a physiological condition in a woman where the reproductive glands stop functioning permanently

MENORRHAGIA

excessive menstrual flow

MIGRAINE

periodic throbbing headaches

MUKHA

mouth

MULA

root or source

MYELOGRAM

a procedure used to diagnose certain spinal problems

MYO

refers to muscle

MYOMATA

abnormal muscle growth in uterus

MYXEDEMA

a condition of under functioning of the thyroid

NATARAJA

god of dance

NEUROPAT HY

disorders of nerves

OCCIPITAL

back portion of the skull

OST EOPHYT E

abnormal bony growth

OST EOPOROSIS

a condition where the bones are demineralised and become porous

OT O

refers to ear

PADA

foot

PADMA

lotus

PALSY

paralysis

PARASYMPAT HET IC

part of the nervous system

PARIVRT TA

rotation

PARKINSON

scientist who described the neurological disease named after him

PASA

noose

PASCHIMA

west

PERISTALSIS

term used for intestinal movements

PHOT OPHOBIA

sensitivity to light

PINCHA

feather

PRASARITA

spread

PROSTAGLANDINS

chemical mediators in metabolism

PSYCHO

refers to mind

RET INIT IS

inflammation of the retina

RHINIT IS

inflammation of the nose

RHINORRHOEA

watery discharge from the nose

SACROILIT IS

inflammation of the sacro-iliac joint

SALABHA

locust

SAVA

corpse

SCLERODERMA

a multisystem disorder, particularly characterized by the skin being tethered down to the underlying surface all over the body

SCLEROSIS

hardening

SCOT OMA

partial loss of field of vision

SET U

bridge

SHANMUKHI

shan = 6; mukha = mouth; refers to the six headed god, Subramania

SINUS

cavity in bone

SIRSA

head

SLE

Systemic Lupus Erythromatosus; a multi-system inflammatory auto-immune disorder

SOMA

body

SPONDYLIT IS

inflammation of vertebral joints

SPONDYLOSIST HESIS

a condition where a vertebra slips forward over another and remains in that position, and may worsen unless corrected

SUPTA

supine

SVANA

dog

TADA

straight, mountain

T HROMBOSIS

occlusion of blood vessels

T INNIT IS

a ringing sensation in the ear

T RENDELENBURG

a scientist who described a certain posture of the body

T RIANGA

three

UJJAYI

a basic type of pranayamic breathing

UPAVIST HA

seated

URDHVA

raised

UT

intense stretch

UT T IHITA

stretched

VARICOSE

dilated and tortuous

VASO

refers to blood vessel

VASOMOT OR

control of blood vessel tone

VEDA

knowledge

VIPARITA

reverse

VRSCHIKA

scorpion

List of Illustrations Photographs Sage Patanjali Sri B.K.S. Iyengar

Asanas Adho Mukha Svanasana (Dog pose)-100, 308 Adho Mukha Svanasana (Dog pose) with rope-50, 358, 374, 432, 446 Adho Mukha Vrsksasana (Hand stand on Slanting plank)-335 Ardha Chandrasana-167, 308, 445 Ardha Matsyendrasana I-311 Ardha Matsyendrasana II-311 Back bend with double ropes-69, 334, 419 Back bend with double ropes, arms behind-100 Back bend with double ropes, arms above head-100 Back bend (spinal extension) in tadasana with neck on rope-419 Baddha Konasana-310 Baddha Konasana with bolster-102 Baddha Konasana on pillow, erect-402 Baddha Konasana with ropes-169 Baddha Konasana, Supta-169, 400, 402, 408 Bakasana-312 Bakasana, Ekapada-313 Bharadwajasana on chair-99, 431 Bharadwajasana on pillow-168 Bharadwajasana near wall, with rope-443 Dandasana with belt for knees-459 Extensor muscles of forearm are weak, evinced by inability to squeeze gripper-136 Forward bend, Cross-legged, with pillow-366, 396 Galavasana-312 Galavasana, Ekapada-313 Halasana-314 Halasana, Half, on stool-336, 416 Hanumanasana-312 Hasta Padangusthasana-457 Hasta Padangusthasana with footrest-444 Hasta Padangusthasana with ropes-99 Janu Sirsasana-310 Janu Sirsasana with pillow-396 Kapotasana, Ekapada raja-313 Krounchasana with belt-101 Kukkutasana-310 Kukkutasana, Parsva-312 Leg inversion, Simple-118 Maha Mudra with rope-401 Marichyasana on floor with pillow-404 Marichyasana, Standing-51, 167 Marichyasana, Standing, with footrest-432, 443 Marichyasana III-311 Natarajasana-314 Neck on rope-97, 139 Padmasana-102

Padottanasana, Prasarita-308 Parsvakonasana with horse prop-445 Parsvakonasana, Parivrtta-307 Parsvakonasana, Parivrtta, with horse prop-445 Parsvakonasana, Uttihita-167, 307 Parsvakonasana, Uttihita, using wall as prop-139 Parsvakonasana, Uttihita, obliquely with ropes-433 Paschimottanasana-310 Paschimottanasana with pillow-396 Pawana Muktasana on stool with pillow-431 Pincha Mayurasana-313 Purvottanasana on pillows-374 Sarvangasana-309 Sarvangasana (Shoulder stand) with belt over arms-96, 123 Sarvangasana on chair-130, 169, 358, 375, 402, 407, 420 Sarvangasana with chair and bandage-335 Sarvangasana on rolled mat-415 Sarvangasana with blankets-413 Sarvangasana, Niralamba (shoulder stand)-122 Sarvangasana, Setu Bandha-46, 309, 412 Sarvangasana, Setu Bandha, with bench and box-336, 359 Sarvangasana, Setu Bandha, with little horse-339, 360 Savasana with pillows, semi-prone-170 Savasana with stool-170 Savasana supine-170 Savasana with weight on forehead-367 Sirsasana (Head stand)-308 Sirsasana on floor-412 Sirsasana on forehead-415 Sirsasana (Head stand) on ropes-168, 334, 358, 374, 393, 402, 407 Sirsasana, Parivrttaika Pada-309 Skandasana-310 Supta Padangusthasana (Hamstring stretch)-101, 120, 310 Supta Padangusthasana with rope (front and side views)-444 Supta Padangusthasana against wall-432 Svanasana, Urdhva Mukha-97 Tadasana with arms over head-460 Tadasana with belt on arms-96 Tadasana with belt for shoulder-460 Tadasana with foot rest-51, 333 Tadasana with hand stretch-136 Tadasana with hand stretch, holding window bar behind back-137 Tadasana, Reverse namaste-96, 135, 460 Tadasana with trapezius traction using rope on shoulders-97, 124, 421 Tadasana, holding window bar-420 Tadasana holding window bar, squatting-99, 460 Tadasana holding window bar, standing straight-98, 460 Trikonasana with horse prop-51, 445 Trikonasana with horse and footrest-339 Trikonasana, Parivrtta-307 Trikonasana, Uttihita-167, 307 Trikonasana, Uttihita, with belt, brick and horse-332 Trikonasana, Uttihita, with heel pushed into footrest-458 Trikonasana, Uttihita, with heel pushed into wall-95 Trikonasana, Uttihita, obliquely with ropes-433 Upavishta Konasana-169, 310, 400, 403 Upavishta Konasana with blankets-101 Urdhva Dhanurasana-314

Urdhva Dhanurasana with ladder stool-337, 359, 375 Uttanasana (right and wrong ways)-447 Uttanasana with arms overhead-137 Uttanasana with arms holding bar above head-460 Uttanasana with footrest-95 Uttanasana with head on stool-95, 396 Uttanasana, Concave-168, 403 Uttanasana, Concave, on horse-400 Uttanasana, Parsva, with heel pushed into footrest-459 Viparita Dandasana on chair with head rest-359, 375, 403 Viparita Dandasana on rack-168 Viparita Dandasana on rack with slanting plank-61, 357 Viparita Dandasana, Dwipada-314 Viparita Dandasana, Dwipada, on barrel drum-337 Viparita Dandasana, Dwipada, on chair-403, 408 Viparita Dandasana, Dwipada, on rack-61, 337 Viparita Karani-65 Viparita Karani on bolster-367 Viparita Karani on pillows-98, 169 Virabhadrasana II with footrest-458 Virabhadrasana III-307 Virabhadrasana III on prop-96 Virasana-102 Virasana in four positions (standing, kneeling, prone, sitting with pillow)-456 Virasana with weight-140, 465 Virasana, Pawana Mukta, with pillow-366 Virasana, Supta-64, 168, 357, 380, 407 Virasana, Supta, on bolster with weight-338 Virasana, Supta, on pillow-98 Virasana, Supta, with pillows between thighs and calves-69 Yoga Dandasana-311

Scans Scan 1 Echo of the heart in supine posture and in head stand-301 Scan 2 Blood flow in the internal carotid artery (ICA) in the erect seated posture-302 Scan 3 Blood flow in ICA in head stand (sirsasana)-302 Scan 4 Blood flow in the middle cerebral artery (MCA) in head stand-303 Scan 5 Blood flow, in head stand, in the ophthalmic vein and the ophthalmic artery-304

Diagrams Fig 1 The simple cell-183 Fig 2 The double helix of the DNA-183 Fig 3 Diagram of a single cell with a semipermeable membrane-184 Fig 4 Squamous epithelium-187 Fig 5 Cuboidal epithelium-187 Fig 6 Columnar epithelium-187 Fig 7 Ciliated columnar epithelium-187 Fig 8 Stratified epithelium-187 Fig 9 Transitional epithelium-187 Fig 10 Areolar tissue-188 Fig 11 Fibrous tissue-188 Fig 12 Elastic tissue-188 Fig 13 Lymphoid tissue-189 Fig 14 Adipose tissue-189 Fig 15 Hyaline cartilage-189

Fig 16 Fibrocartilage-190 Fig 17 Elastic fibrocartilage-190 Fig 18 Ciliated columnar epithelium with goblet cells-190 Fig 19 The knee joint: Section viewed from the side-191 Fig 20 The skin showing the main layers of the epidermis-192 Fig 21 Main structures in the dermis-193 Fig 22 The nail and related skin-193 Fig 23 The bony skeleton-195 Fig 24 A bone shaft in cross section reveals spongy internal structure-195 Fig 25 Cross section of microscopic structure of bone-195 Fig 26 Longitudinal section of microscopic structure of bone-195 Fig 27 A mature long bone, longitudinal section-196 Fig 28 Irregular bone-196 Fig 29 Flat bone-196 Fig 30 The bones of the face (anterior view)-197 Fig 31 The bones of the skull and their joints or sutures-197 Fig 32 Lateral view of the vertebral column-197 Fig 33 A cervical vertebra-198 Fig 34 A thoracic vertebra-198 Fig 35 A lumbar vertebra-198 Fig 36 The sacrum and coccyx-198 Fig 37 Lower cervical vertebra separated to show the spinal cord and spinal nerves emerging through the intervertebral foramina-198 Fig 38 The thoracic cavity-199 Fig 39 Organs occupying the anterior part of the abdominal cavity-199 Fig 40 Organs occupying the posterior part of the abdominal cavity-200 Fig 41 A fibrous or fixed joint (eg: the sutures of the skull)-201 Fig 42 A cartilaginous or slightly movable joint-201 Fig 43 The shoulder joint (section viewed from the front)-202 Fig 44 Section of the elbow joint, partly flexed, viewed from the side-202 Fig 45 Section of the wrist and distal radioulnar joints (anterior view)-202 Fig 46 Carpal tunnel, synovial sheaths and tendons of the wrist and hand-202 Fig 47 Section of hip joint (anterior view)-203 Fig 48 Supporting ligaments of hip joint-203 Fig 49 Head of femur and acetabulum separated to show acetabular labrum and ligament of head of femur-203 Fig 50 The knee joint: superior surface of the tibia-204 Fig 51 Section of left ankle joint (viewed from the front)-204 Fig 52 Supporting ligaments of left ankle joint-205 Fig 53 Striated muscle fibre & bundle of striated muscle fibres with connective tissue-206 Fig 54 Arrangement of actin, tropomyosin and the three subunits of troponin-206 Fig 55 Diagram of electron micrograph of human gastrocnemius muscle-207 Fig 56 Muscle contraction and relaxation-207 Fig 57 Cardiac muscle fibres-208 Fig 58 Smooth muscle fibres-208 Fig 59 Main muscles of the face, head and neck-209 Fig 60 Main muscles which move the joints of the upper limb-209 Fig 61 Main muscles of the back-210 Fig 62 Muscles of the abdominal wall-211 Fig 63 Cross-section of fascia of muscles of the anterior abdominal wall-211 Fig 64 Muscles of the pelvic floor-211 Fig 65 Main muscles of the lower limb-214 Fig 66 Position of heart in the thorax-215 Fig 67 Organs associated with the heart-215 Fig 68 Interior of the heart-217 Fig 69 Coronary arteries-217 Fig 70 Conducting system in the heart and the flow of blood through it-217 Fig 71 Aorta and main arteries of the limbs-218 Fig 72 Arch of the aorta and its branches-219 Fig 73 Structure of an artery and a vein-219

Fig 74 Interior of a vein-219 Fig 75 Diagram showing the beginning of a lymph capillary in the interstitial space-219 Fig 76 Arteries forming the circulus arteriosus and its main branches to the brain-220 Fig 77 Main arteries of head and neck-220 Fig 78 Abdominal aorta and its branches-221 Fig 79 Coeliac artery, its branches, and the inferior phrenic arteries-221 Fig 80 Venae cavae and main veins of the limbs-222 Fig 81 Section of a lymph node-223 Fig 82 Some lymph nodes of the face and neck-223 Fig 83 Some lymph nodes of the upper limb-224 Fig 84 The spleen-225 Fig 85 Thymus gland and related structures in the adult-225 Fig 86 Blood cells through a microscope-227 Fig 87 The organs of respiration-231 Fig 88 Lateral wall of the right nasal cavity-231 Fig 89 Pathways of air from the nose to the larynx-232 Fig 90 Interior of the larynx seen from above-232 Fig 91 The trachea and associated structures-233 Fig 92 A lung lobule-233 Fig 93 Capillary network surrounding the alveoli-233 Fig 94 Diagram of interchange of gases in the alveoli and the blood capillaries-234 Fig 95 The intercostal muscles and the bones of the thorax-234 Fig 96 Some of the nerves involved in control of respiration-235 Fig 97 Diagram of interchange of gases during internal respiration-235 Fig 98 Organs of the digestive system-236 Fig 99 General plan of the alimentary canal-236 Fig 100 The peritoneum-237 Fig 101 Structures in the mouth, including the papillae of the tongue-238 Fig 102 The permanent teeth and jaw bones-238 Fig 103 Section of a tooth-238 Fig 104 Position of the salivary glands-239 Fig 105 Esophagus and associated structures-239 Fig 106 Positions during swallowing of structures in the head and neck-239 Fig 107 Longitudinal section of stomach-240 Fig 108 Muscle fibres of the stomach wall-240 Fig 109 The pancreas-240 Fig 110 Anterior view of the liver-241 Fig 111 The small and large intestines and their associated structures-242 Fig 112 Diagram of absorption of nutrient materials-242 Fig 113 Diagram showing autonomic nerve supply to the digestive system-243 Fig 114 Anterior view of kidneys showing areas of contact with other structures-244 Fig 115 Longitudinal section of right kidney-244 Fig 116 Diagram of a nephron with the glomerulus and glomerular capsule-245 Fig 117 The ureters in relation to the kidneys and the bladder-245 Fig 118 Positions of the endocrine glands in the body-247 Fig 119 Parts of the pituitary gland and its relation to the hypothalamus-248 Fig 120 The thyroid gland and associated structures-249 Fig 121 The parathyroid glands and related structures-249 Fig 122 The adrenal glands in relation to the kidneys and other structures-250 Fig 123 A neurone-251 Fig 124 Diagram of a synapse, indicating dendrites and axons-252 Fig 125 Section of a synapse-252 Fig 126 Sensory nerve endings in the skin-252 Fig 127 Longitudinal section of a motor unit-252 Fig 128 Parts of the central nervous system and the functional areas of the cerebrum-253 Fig 129 The cerebellum and its associated structures-253 Fig 130 The internal capsule and its connections with the spinal cord-254 Fig 131 Layers of the spinal cord-255

Fig 132 Section of the distal end of the vertebral canal-255 Fig 133 A simplified diagram of the main tracts of the spinal cord-256 Fig 134 The right sympathetic trunk-257 Fig 135 Position of the vagus nerve in the thorax-257 Fig 136 The spinal cord and the spinal nerves-259 Fig 137 Diagram showing relationship between sympathetic and mixed spinal nerves-260 Fig 138 The main nerves of the arm-260 Fig 139 The main nerves of the leg-260 Fig 140 The optic nerve and the visual pathway-261 Fig 141 Parts of the ear-262 Fig 142 The internal ear-262 Fig 143 Section of membranous cochlea showing the organ of Corti-263 Fig 144 Choroid, ciliary body and iris-264 Fig 145 Section of the eye and the focusing of light rays on the retina-264 Fig 146 The retina as seen through the pupil-265 Fig 147 The extrinsic muscles of the eye-265 Fig 148 The lacrimal apparatus showing the direction of flow of tears-265 Fig 149 The olfactory structures-266 Fig 150 The male reproductive organs and associated structures-267 Fig 151 Longitudinal section of a testis, its coverings, and a deferent duct-267 Fig 152 Section of prostate gland and associated reproductive structures on one side-268 Fig 153 A spermatozoon-268 Fig 154 The external genitalia in the female-269 Fig 155 Female reproductive organs in the pelvis and associated structures-269 Fig 156 Female reproductive organs in pelvis & main ligaments supporting the uterus-270 Fig 157 Section of the uterus-270 Fig 158 Section of an ovary showing the stages of development of one ovarian follicle-271 Fig 159 The breast-271 Fig 160 Atherosclerosis-355 Fig 161 Lungs affected by emphysema-372 Fig 162 Stages of descent of prolapsed uterus-406 Fig 163 Spondylitis of the cervical spine-418 Fig 164 Right vertebral artery coursing through the neck to the base of the brain-418 Fig 165 Conditions, other than protruding discs, that cause pain in lower back or leg-422 Fig 166 Typical locations of tenderness in relatively superficial back muscles, following sprains of their myotendinous junctions-423 Fig 167 The lumbar fibres of iliocostalis-425 Fig 168 The thoracic fibres of iliocostalis lumborum-425 Fig 169 The lumbar fibres of longissimus-426 Fig 170 The thoracic fibres of longissimus-426 Fig 171 The erector spinae aponeurosis (ESA)-427 Fig 172 The component fascicles of the multifidus-429 Fig 173 The diaphragm-430 Fig 174 Lumbar vertebra, top view-435 Fig 175 Division of a lumbar vertebra into its three functional components-435 Fig 176 Joints between two lumbar vertebrae, lateral view-435 Fig 177 Internal architecture of vertebral body-435 Fig 178 Zygapophyseal joints L3?4, posterior view-435 Fig 179 Structure of an intervertebral disc-436 Fig 180 Function of the intervertebral disc-436 Fig 181 The anterior longitudinal ligament and the inter-transverse ligaments-437 Fig 182 A median sagittal section of the lumbar spine to show its various ligaments-437 Fig 183 The ligamentum flavum at the L2-3 level-437 Fig 184 Compression injury of an intervertebral joint-439 Fig 185 Disc degradation and internal disc disruption-439 Fig 186 Herniated disc-440 Fig 187 Contents of sciatic foramina-441 Fig 188 Spondylolisthesis is the forward shift of one vertebra over another-448 Fig 189 Scoliosis with convexity to the right-451

Fig 190 A normal heel bone (calcaneum) and one with spur-464

Index A Abhinivesa, 9 Abhyasa, 8 Abortion, 160 Adhibhautika roga, 59 Adhyatmika roga, 59 Adidaivika roga, 59 Adipose tissue, 189 Adrenal Axis, 76 Adrenal glands, 249 Aging, 44 Aging of the disc, 438 Ajna Chakra, 277 Alzheimer’s disease, 467 American football, 94 Anahata Chakra, 277 Ancient thought on food, 35 Angina, 364 Angioplasty, 354 Anti-diuretic hormone, 76 Apana, 2, 278, 344 Appendicular skeleton, 198 Ara mandi, 116 Archery, 73, 89, 114 Archives of Internal Medicine, 79 Archives of Physical Medicine Rehabilitation, 79 Areolar tissue, 188, Arrhythmias, 357, 362, 383 Arteriosclerosis, 355 Artha, 12 Arthritic hips and ankles, 458 Arthritic shoulders, wrists and fingers, 458 Asanas in a seated position, 317 Asmita, 9, 55 Atha yoga anushasanam, 8, 145 Atherosclerosis, 56, 111, 284, 289, 467, 391 ATP, 26, 81, 184, 191, 360 Aurobindo, 7, 10 Autonomous nervous system, 65, 132, 143, 174, 251, 255, 258, 264, 371, 414 Avidya, 9

Ayurveda, ix, 3, 6, 7, 11, 70, 469 B Back bending asanas, 46, 61, 64, 85, 173, 292, 321, 361 Balancing asanas, 142, 320 Ballet, 117 Belts, 333, 457 Bench, 332, 336 Bhaja Govindam, 56 Bharatanatyam, 116 Bhastrika, 327 Bile acids, 23, 241 Billiards, 103 Bladder, 48, 245 Blood, 227 Blood flow in middle cerebral artery, 303 Blood pressure, 362 Bolster and pillow, 332, 337 Bone, 194 Boxing, 103 Brahman, 35 Brain, 251 Bronchi, 231 Bronchial asthma, 369 Bursae, 190 Bypass surgery, 353 C Calceneal spur, 464 Carbohydrates, 26 Cardiac muscle, 208 Cardiomyopathy, 361 Cartilage, 189 Catecholamines, 65, 76, 250 Cell, 191 Cellulose, 26 Cerebral circulation, 220 Cervical spondylitis, 417 Chandogya Upanishad, 36 Charaka Samhita, 70 Cholesterol, 22 Chronic Bronchitis, 372 Chronic Sinusitis, 413

Chylomicrons, 23 Clin. Sports Med, 106 Connective tissue, 187 Coronary angiogram, 353 Coronary circulation, 221 Cricket, 91 Cycling, 107 D Darsanopanishad, 4 De Quervain’s disease, 136 Devadatta, 278 Dhananjaya, 278 Dhanvanthiri, 11 Dharma, 6, 12 Dharmameghah Samadhi, 12 Diabetes Mellitus, 27, 382 Discus, 88 DNA, 183 Duodenal ulcer, 378 Dysmenorrhoea, 398 E Ear, 262 Echo of heart, 300 Ectopic, 362 Elastic tissue, 188 Emphysema, 372 Epithelial tissue, 187 Esophagus, 238 Essential hypertension, 362 Ethnic dance, 118 Exercise vs drugs, 144 Eye, 263 F Fallopian tubes, 269 Fat metabolism, 23, 77, 241 Fats, 22 Female hormones, 147 Fiber, 27 Fibroids, 401 Fibrous joints, 201 Fibrous tissue, 188

Five elements, 4 Football, 93 Footrest, 333 Free radicals, 185, 288, 327, 360 Functions of muscles, 212 Functions of the disc, 436 G Gall bladder, 241 Gastric ulcer, 377 Gemfibrosil, 23 Glucagon, 76 Glucose, 26 Glycogenolysis, 26 Glycolysis, 26 Golf, 91 Gouty arthritis, 453 Growth hormone, 76 Gunas, 8 Gymnastics, 106 H Hammer, 88 Hamstrings, 90, 114, 125, 213, 440 HDL, 23, 77 Healthy pain, 295 Hemi-cellulose, 26 Heyam Dukham Anagatam, 18, 283 Hibernative exercise, 288 High jump, 87 Homeopathy, 348 Horse 332 Hot flush, 141 Hyperventilate, 328 Hypothyroidism, 25, 34, 131, 150, 159, 175, 203, 226, 349 I Ida, 397 Immunity, 39, 65, 142, 152, 179, 228, 229, 230, 414 Insomnia, 17, 19, 111, 134, 135, 144, 305 Internal capsule, 253 Inverted poses, 299 Ishwarapranidhana, 7, 9, 53, 114, 127 Iyengar yoga, xiii, xiv, xv, 15, 16, 46

J JAMA, 79, Javelin, 88 Jazz dance, 117 K Kaivalya pada, 6, 11 Karma, 10, 14 Kathak, 116 Kathakali, 117 Kathopanishad, 6, 277 Kriya yoga, 9 Krkara, 278 Kurma, 278 L Lactic acid, 26, 27, 80, 355 Lalata charka, 277 Larynx, 231, 232 LDL, 23, 109, 356, 385 Lipid peroxidation, 288 Long jump, 87 M Mahabhasya, 6 Mammary glands, 271 Manas charka, 277 Manipuraka charka, 277, 278 Manipuri, 116, 117 Meditation, 4, 6, 8, 9, 10, 11, 19, 40, 44, 63, 114, 135 Menopausal women, 31, 51, 79, 83, 135 Menstrual rhythm, 149 Metaplasia, 191 Middle ear, 232, 262 Migraine, 16, 134, 305, 349, 393, 394 Modern or American dance, 117 Moksa, 12 Moss on the walls, 45 Motorcycling, 108 MSSE, 36, 73, 77, 83, 84, 105, 113, 287 Muladhara charka, 276 N

Nadi, 3, 4, 20, 277, 278 Nadis, 299, 346 Naga, 2, 278 Natur.Cancer, 66 Natural puncture, 415 Neoplasia, 191 Nephrons, 244 Neurone, 251 Nicotine, 5, 26, 56, 57 Niyama, 6, 7, 9, 10, 12, 17, 41, 66, 70, 113, 144, 290, 346 O Obesity, 24, 144, 331, 401, 448, 453 Occupation and Environmental Medicine, 284, 289 Osteo-arthritis, 25, 50, 123, 204, 287, 349, 453, 457 Osteology, 194 Ovaries, 157, 175, 247, 267, 269, 298, 399, 404 Overtraining syndrome, 110, 113 Overweight, 26, 104, 132, 133, 318, 363 P Pacemaker, 209, 216 Painting and sculpting, 123 Pancreas, 25, 47, 49, 57, 76, 105, 132, 152, 200, 219, 237 Parasympathetic system, 232, 242, 251 Parathyroid glands, 247, 249 Patanjali, 1, 2, 3, 5, 6, 9, 11, 17, xvii Penis, 162, 192, 267, 268, 276 Peptic ulcer, 2, 35, 57, 59, 62, 63, 65, 124, 243, 325, 330, 335, 345, 377, 379, 381 Percussion instruments, 116, 120 Peripheral nervous system, 152, 174, 251, 256, 258, 261, 299 Pharynx, 231, 232 Pineal gland, 247, 250 Pingala, 176, 276, 278, 327, 397 Piriformis syndrome, 442 Pituitary gland, 34, 49, 148, 150, 153, 196, 247 Plasma, 31, 227 Platelets, 227 Pole vault, 87 Polo, 94, 114 Portal circulation, 28, 219 Pose and counter pose, 295 Prana, 10

Pranayama, 11, 68, 73, 93, 106, 174, 176, 327, 343, 345, 346, 351, 354, 360, 397, 416 Pranayama and atmospheric damage, 289 Pratyahara, 6, 10, 53, 114, 174, 274, 380, 395 Prolapse of the uterus, 333, 405 Prostate, 48, 268 Protein (amino acid metabolism), 14, 21 Proteins, 384, 385 Psychosomatic, 2, 24, 133, 134, 326, 399 Pulmonary circulation, 125, 219, 223, 303, 322 R Raga, 9, 11, 55 Ramana Maharishi, 2 Receptors alpha and beta, 75, 76, 157, 185, 186 Rheumatoid arthritis, 160, 204, 228, 349, 462 Rowing, 73, 79, 110, 114 Running, 79, 83-87, 94, 114, 289 S Sadhana Pada, 1, 2, 3, 6, 9, 19, 55, 56, 145, 290, 295, 326, 330 Sahasrara Chakra, 277 Sai Baba, 10, 67, 71 Salivary glands, 186, 236, 238, 239, 284, 315, 328 Samadhi, 6, 7, 11, 12, 16, 53, 114, 127 Samadhi pada, 1, 6, 8, 59, 145, 287 Samana, 278 Sammatwam yoga uchathe, 17 Scoliosis, 297, 451, 452 Senile dementia, 49, 133, 301, 467 Shooting, 73, 89, 114 Shotput, 88, 114 Sitali, 87, 91, 93, 108, 122, 176, 279, 327, 328, 397, 470 Siva Samhita, 277, 278 Skiing, 73, 109 Skin, 109, 116, 119, 124, 132, 140, 142, 154, 165, 178, 186, 188, 192 Skull, 103, 154, 194 Slanting planks, 97, 332, 335 Small intestine, 22, 28, 33, 223, 224, 237, 242 Smooth muscle, 148, 206, 208, 209, 210 Soma, 2, 325 Soma charka, 277 Spinal cord, 97, 197, 248, 251, 299, 320, 423 Spinal nerves, 174, 197, 205, 251, 320, 388, 443

Spondylolisthesis, 297, 448 Sports anemia, 111 Squash, 90, 114 Stages of human fetal development, 152 Standing poses, 295 Sthula sarira, 276 Stira Sukham Asanam, 17, 295 Stomach, 22, 27, 239 Stool, 336 Stretching is important, 273 Striated muscle, 206, 264 Stringed instruments, 119 Stroke, 24, 49, 133, 294, 301, 302, 392 Suksma sarira, 276, 278 Surya charka, 277 Susruta Samhita, 70, 71 Susumna, 4, 277, 278 Svadhisthana charka, 277 Swatmarama, 10, 67, 291 Swimming, 73, 79, 108 Sympathetic system, 75, 256, 356, 367, 396 Synovial joints, 201 T Tap dance, 118 Tapas svadhyaya, 9 Taste buds, 237, 266 Teenagers, 41 Tendons, 208 Tennis, 79, 89, 114 Testes, 247, 248, 268 Thrombosis, 162, 266, 297, 333, 355, 356, 390 Thyroid gland, 34, 76, 153, 247, 248 Tissues, 191 Triglycerides, 22, 77, 241, 356 Triple jump, 87 Trishaki Upanishad, 3 Twisting poses, 318 U Udana, 278 Ujjayi, 122, 327, 372, 375, 397, 401 Ureters, 155, 173, 245

Urethra, 246 Uterus, 43, 48, 139, 270 V Vagina, 269 Vairagya, 8, 9 Varahopanishad, 4 Vascular Biology, 355 Vasodilators, 353, 361, 364 Vasomotor Rhinitis, 410 Venous system, 224, 302, 318 Vertebral column, 79, 195 Vibhuti Pada, 6, 10, 279 Visuddhi charka, 277 Vital capacity, 24, 46, 47, 130, 234, 375, 387 Vitamins, 12, 21, 28 Vitarkabhadane pratipaksa bhavanam, 10, 290 VLDL, 23 Vyana, 278 W Weightlifting, 104, 106, 114 Weights, 91, 338 Western musical instruments, 122 White blood corpuscles, 58, 150, 227, 230 Wind instruments, 121 Wooden brick, 332 Wrestling, 104 Y Yama, 7 Yoga and preventive care, 5 Yoga as a diagnostic tool, 3 Yoga compared to other systems of exercises, 291 Yoga Sutras, 1, 6, 8, 12, 16 Yoga Upanishad, 2 Yoga Vasishta, 5, 19, 45, 53, 54, 67, 144, 348 Yogic charkas, 276, 324

Notes

Notes