A Guide for Physiotherapists

by Simon Borg-Olivier & Bianca Machliss

(A paper Presented at “The Australian Physiotherapy Association Conference for Alternative Therapies”, at Byron Bay, Australia July 1997)

Introduction

Yoga has a recorded history of at least five thousand years (Feuerstein, 1996). Hatha yoga involves the physical aspect of this ancient Indian science. Some of the elements of Hatha yoga include:

1. aerobic conditioning
2. isometric and isotonic muscle strengthening,
3. stretching exercises and postures (asanas),
4. relaxation,
5. breath control,
6. concentration, and
7. meditation.

Yoga is literally a holistic system. The word ‘yoga’ means union, joining, or to link together an one whole. Feuerstein, (1996) describes the yoga approach as simplifying one’s consciousness and energy to the point where we no longer experience any inner conflict and are able to live in harmony with the world.

Hatha yoga is a physical method which uses the breath to link the various parts of the body and the mind and to allow them to behave as one functional unit. In practice, some, or all, of the elements of Hatha yoga listed above, may be performed concurrently. For example, one muscle may be stretching, another muscle contracting, and another relaxing, while there is an ongoing concentrated awareness of the breath.

Types of Yoga Available

There are many types of yoga being taught in the west today. The names used to describe different types of yoga are often arbitrary and sometimes misleading. Many styles of yoga, such as Raja yoga or Siddha yoga involve mainly meditation and relaxation with only a small physical component. The more dynamic styles are usually types of Hatha yoga, but may be advertised as Iyengar yoga or Ashtanga Yoga. Australia probably has the largest number of teachers and schools of yoga per capita in the world. However not all yoga classes are well taught, and not all yoga teachers have a sufficient knowledge of anatomy and physiology to teach yoga classes which are safe for everyone. We suggest that before recommending a particular yoga teacher to one of your clients that you first attend at least one of that teacher’s classes. Probably the best physical yoga taught in the world today comes from the teachings of Professor T. Krishnamacharya, who died in 1989 at the age of 101. Krishnamacharya was the teacher of 3 of the most influential yoga masters alive today. These yoga masters are B.K.S. Iyengar, who wrote the classic yoga text called ‘Light on Yoga'(1966); K. Pattabhi Jois who teaches the very dynamic ‘Ashtanga Vinyasa Yoga’; and, T.K.V. Desikachar (1995), who teaches a softer more gentle style of yoga. In our opinion teachers trained in the Iyengar method have the best understanding of physiology and correct musculoskeletal alignment. There are about 100 teachers in Australia who are certified to teach yoga using the Iyengar method. If you are looking for a good yoga teacher then we suggest you telephone the ‘B.K.S. Iyengar Association of Australia Incorporated’ (phone: 02 9948 2365 or 1 800 677 037).

Anatomy and Physiology of Hatha Yoga:

General Physiology of Hatha Yoga:

Beneficial side effects of practicing Hatha yoga may include increases in strength, flexibility and the ability to relax. However, one of the main physiological purposes of Hatha yoga is to improve the circulation in the body. In fact, stimulating the circulation is one of the main ways Hatha yoga actually works.

The word ‘Hatha’ means force, and can represent pressure (Pressure = Force per unit Area). The sound ‘Ha’ is Sanskrit for the sun which represents heat or high pressure. The sound ‘Tha’ (pronounced ‘Ta’) is Sanskrit for the moon which represents coolness or low pressure.

Hatha yoga sets up regions of relative high pressure and low pressure within the body which help stimulate circulation in the same way that the heart, and the musculoskeletal pump works.

Hatha yoga sets up differential pressures within the body using:

1. conscious contraction of muscles (which increases local pressure) and relaxation of muscles (which leads to a relative decrease in local pressure), in addition to the actions of the musculoskeletal pump;
2. expansion and contraction of the thorax during specific breathing exercises, in addition to actions of the respiratory pump;
3. the effects of the force of gravity which is especially noticeable in the inverted and semi inverted postures the yoga system offers;

and

1. the yoga asanas (postures) themselves, which physically compress some parts of the body (i.e. increasing local pressure), while stretching other parts of the body (i.e. decreasing local pressure);

As soon as a relative difference in pressure comes into existence within the body, there is a physiological tendency for blood and intracellular fluid, to move from the region of higher pressure towards the region of lower pressure.

The circulation of body substances, through blood vessels and intracellular spaces, between two different body parts, increases proportionally as the relative difference in pressure between the two body parts increases. Therefore, to achieve maximum stimulation of circulation with a minimum of effort it is important that one part of the body is kept at a very low pressure. This is one reason why the face and neck are usually kept completely relaxed (i.e. at a low pressure) while doing yoga.

Efficient circulation is essential for health because it enhances the delivery of nutrients and the removal of metabolic wastes from each of the body cells, but in yoga terms it has one more essential function. Efficient circulation enhances communication between cells via the transportation of biochemical signals such as hormones, neurotransmitters and immunotransmitters. The newly emerging field of psychoneuroimmunology (Maier et al., 1994) considers these biochemical signals to be at the core of our thinking process, therefore their transport can be thought of as the physiological basis for the mobilisation of consciousness throughout the body. Psychoneuroimmunology is the study of the interrelationships between psychological, neuroendocrine, and immunological parameters, and is concerned with how these relationships may affect an individual’s health. Substantial evidence indicates that exercise is associated with improvements in mental health, neuroendocrine, and immune functioning (La Perriere et al, 1994). Yoga and psychoneuroimmunology are both holistic approaches to health. The close relationship between psychoneuroimmunology, meditation, and holistic medicine is discussed by Ward (1995).

Musculoskeletal Anatomy of Hatha Yoga Postures:

This section is intended as a brief introduction to some common features of many of the Hatha yoga exercises. A more complete understanding may be achieved when the exercises are demonstrated by an experienced practitioner.

Yoga exercises are mostly thought of as stationary and isometric, however they may also be extremely dynamic, with varied velocity of movements. In addition to isometric muscle contractions, both concentric and eccentric muscle activity is incorporated.

Yoga exercises include many postures which are weight bearing (WB) on any combination of the upper and lower limbs, and postures which are non weight bearing (NWB). Hence yoga incorporates both open and closed kinetic chain exercises for the upper and lower limb.

Yoga practitioners also learn how to generate tension and relax their muscles when their muscles are in either a lengthened or shortened state. Hence muscles are taught to be functional throughout a full range of motion (ROM). In addition, postural muscles are also toned, activated and controlled throughout ROM whilst going into, being in, and coming out of postures.

Yoga can have an effect on the nervous system because the postures can tension specific nerves. Also, by applying a practical understanding of spinal reflexes, such as the stretch reflex and reciprocal reflex relaxation, the yoga practitioner is able to consciously relax a muscle and further deepen its relaxation by contraction of the antagonist.

The Hatha Yoga Asanas (Postures and Exercises):

Hatha yoga postures or exercises, which are known as asanas, include those which are standing, sitting, supine, prone, and, inverted or semi inverted. Many of the exercises prescribed by physiotherapists resemble Hatha yoga asanas.

Yoga asanas aim to develop a balance between strength and flexibility. All of the major joints in the body are addressed in the many yoga postures. For each joint there exists a combination of asanas which will help to strengthen the muscles around the joint, and help to bring a functional stability to that joint, through a full ROM.

Several yoga asanas, in particular the inverted postures, have been labelled as dangerous by certain sectors of the health profession. However, any exercise can be dangerous if done incorrectly, or if given to someone who should not be doing it. Traditional yoga asanas such as the headstand, shoulderstand, and plough pose, should only be attempted by advanced practitioners, who have no restricting musculoskeletal pathology or medical condition, and who are taught by a competent and experienced teacher.

In this seminar you will be shown a series of asanas which can easily be adapted for most students who do not have severe musculoskeletal or medical restrictions. Each asana has a range of simple to hard variations. When attempting each asana the following points should be noted:

1. Attempt each asana only to a level such that there is no strain.
2. The face muscles should be completely relaxed.
3. The lower back and neck should not feel ‘squashed’.
4. The knees should not feel painful.
5. Breathing should be relaxed.

The following sections briefly outline some of the considerations to be made while performing the asanas with respect to postural alignment, joint positions, muscle contractions, and relaxation of muscles. The asanas that are presented here are intended for people who have no severe musculoskeletal or medical problems. However, asanas may be suitably adapted for people requiring therapy if they are taught by an experienced yoga practitioner who has a sound understanding of anatomy and physiology. More information about how to perform the exercises can be obtained from a number of commercially available books including Iyengar’s (1966) classic text “Light on Yoga” and other more recent works by other authors (Iyengar, 1982; Mehta et al, 1990; Desikachar, 1995).

The Feet and Ankles:

In the standing yoga postures students are taught how to stabilise the ankle joint by co-contracting the muscles around the ankle. First, students are told to press down onto the base of the big toe, and shown how to contract Peroneus longus. Then they are told to lift the inner arch of the foot and shown how to contract Tibialis posterior. In order to reflect the holistic nature of yoga students are taught feel the effect the feet have on the functioning of the whole body.

The Knee and Thigh:

Assuming a yoga student has a normal range of knee flexion and extension then the most important issues to be addressed while performing the yoga postures are:

1. increasing knee stability;

and

1. increasing the flexibility, strength and control of the hip and ankle joints.

Students are taught to increase the stability of their knee by co-contraction of the muscles crossing the knee joint. Co-contraction of the muscles around the knee can initially be achieved using several methods. One closed kinetic chain exercise which helps elicit a co-contraction around the knee joint involves standing erect and firmly contracting the quadriceps, then attempting to flex the knees by contraction of the hamstring muscles. One open kinetic chain exercise which helps elicit a co-contraction around the knee joint is described in the section on the hip and pelvis.

Hamstring flexibility is developed rapidly with correctly applied yoga stretches. During hamstring stretches the quadriceps are kept active in order to keep the knee fully extended and in order to help give reciprocal relaxation to the hamstrings. Students are shown how to maximise the distance between origin and insertions of the hamstring group by using an anterior pelvic tilt rather than using spinal flexion.

Well taught yoga classes actively encourage safety of the knee joint. In the lunging standing postures students are told to keep their knees directly over their heels to minimise the stress on their patello femoral joint. In the straight legged standing postures students are shown how to avoid hyperextension of the knee joint by exerting greater pressure with the forefoot and less with the hindfoot on the floor, thus activating the Gastrocnemius muscle which causes a slight flexion moment at the knee joint.

The Hip and Pelvis:

Flexibility of the hip joint is very important in the yoga postures. Until a full range of movement is available in this joint many yoga postures can only be attempted if they are modified or if they are done in conjunction with props.

Hip flexor flexibility is developed through postures in which posterior pelvic tilt is taught while the hip is kept in some internal rotation to increase the stretch on the iliopsoas muscle. Hip flexor muscle contractions may be used in the ‘forward bending’ (hip and spinal flexion) postures as a means of increasing anterior pelvic tilt to decrease the spinal flexion and to increase the stretch on the hip extensors.

In many asanas the hamstrings can be used to extend the thigh at the hip joint, while the lower limb is part of an open kinetic chain. In order to maximise the use of the hamstrings as hip extensors it is necessary to relax first gluteus maximus by internally rotating the thigh at the hip joint. In one such asana, known as Virabhadrasana III, which is a one legged posture with both knees extended, the WB hip in flexion, and the NWB hip in extension and internal rotation, there are several effects:

1. activation of the hip adductor muscles which serve as hip internal rotators (Norkin and Levangie, 1992),
2. activation of the Vastus medialis via its attachments to the hip adductors,
3. eciprocal relaxation of the external rotators of the hip including Gluteus maximus;

and

1. contraction of the hamstrings, which act as hip extensors.

These muscle movements and relaxation of this asana have the following beneficial effects on the sacro-iliac (SI)joint and the knee.

• The SI joint is gently tractioned, due to the active internal rotation of the thigh at the hip joint while the hip is extended by the hamstrings and the buttocks kept relaxed
• There is co-contraction of the muscles around the knee joint of the NWB limb.

Hatha yoga incorporates many one-legged postures. These poses are excellent strengthening exercises for the hip abductors of the standing leg and the hip joint in general (Norkin and Levangie, 1992). Recent evidence suggests that the contralateral leg also gets a significant training effect (Kannus et al, 1992). In the one legged balance where the arms pull one knee to the chest (known as Utthita Padangusthasana), the hamstrings of the standing leg are activated in order to keep the standing hip in extension, but because the inferior thigh is being drawn posteriorly another effect of the hamstring contraction is to extend the knee.

The Shoulder complex:

Correctly applied yoga exercises develop flexibility of shoulder complex in conjunction with stability and control of movement.

Yoga students are taught how to control the depressors to the shoulder complex. Latissimus dorsi, and Pectoralis major are actively contracted in many of the yoga postures. The contraction of these muscles serves several functions:

1. to strengthen these muscles;
2. to assist the rotator cuff in stabilising the glenohumeral (GH) joint;
3. to assist in the reciprocal relaxation of the shoulder elevator muscles which tend to be chronically overactive and tense in many people;

and

1. to depress the shoulder when the arm is engaged in an open chain exercise, or to elevate the chest and thorax when the arms are engaged in certain closed chain exercises.

Correct positioning of the shoulder complex can assist in the mobilisation of the thoracic spine. For example in many yoga poses students are shown how to keep the arm extended and externally rotated at the GH joint with the scapular protracted. In this position the scapular is able to exert a pressure against the thoracic cage which can help mobilise the thoracic spine, especially if the upper limb is engaged in a closed chain exercise.

The Spine and Trunk:

The yoga postures are designed to give strength and flexibility to the spine. Strength in the spine is developed and maintained in yoga postures by a muscular contraction of the lower trunk which is known in yoga as a bandha or lock.
This bandha is essentially a gentle tonic contraction of:

1. the lower back musculature, in particular Multifidus,
2. the muscles of the perineum,

and

1. the lower abdominal musculature, in particular the Transversus abdominis.

As the difficulty of a particular asana increases, other muscles of the lower back such as the Erector spinae, and other abdominal muscles are also contracted.

Spinal flexibility is achieved by the use of the various postures and breathing exercises which when performed correctly not only move the spine into flexion, extension, lateral flexion and rotation, but they can also gently traction the spine.

A normal spine usually consists of flexible regions and ‘stiff’ regions. In many of the yoga postures the bandhas are used to stabilise the more flexible and generally weaker areas of the spine, such as those in the lumbar region, so that less flexible areas of the spine, such as those in the thoracic region, can be encouraged to move. To self mobilise the thoracic spine in yoga the musculature of the area should be kept as relaxed as possible, and the muscles of the arms and legs should be used in such a way as to lengthen spine. Students are shown and taught how to use the muscular actions and positioning of the upper and lower limbs to lengthen and mobilise their spines.

Cardiopulmonary Considerations in Hatha Yoga Exercises:

There are many reports in the literature of yogic control of autonomic functions via the use of advanced breathing control. Experienced Hatha yoga practitioners are able to perform a variety of advanced breathing techniques, such as very slow deep breathing. However, these advanced breathing techniques are not suitable for beginner yoga practitioners, as they are potentially dangerous. New yoga students are always advised to breathe in a normal relaxed fashion. Students are taught how to keep their face and neck relaxed while breathing and avoid the use of their accessory breathing muscles. In the initial stages students are also warned against breathing too deeply as this often leads to hyperventilation, unless the increase in their tidal volume is associated with a decrease in the number of breaths per minute. Students are also warned against contracting their abdominal muscles towards the end of inhalation (i.e. performing a Valsalva manoeuvre) as this has been shown to increase blood pressure during and after isometric exercise (O’Connor, Sforzo and Frye, 1989) and can also lead to an increase in intercranial pressure.

Reported Benefits of Hatha Yoga and the Scientific Validity of these Reports:

A MEDLINE literature search on ‘yoga’ reveals that their are currently 434 scientific articles written since 1965 regarding yoga. Unfortunately very few of these articles are randomised controlled trials. Hence the validity of their claims is not assured. However, these articles report a number of benefits of yoga including increased strength and flexibility, stress relief, increased concentration, improved lung function, increased aerobic ability, improved emotional state, and improvement in the condition of pathologies such as asthma, bronchitis, osteoarthritis, rheumatoid arthritis, epilepsy and diabetes.

Although there is a paucity of randomised controlled trials specifically on yoga, there are some quite good scientific studies reported on some of the elements of yoga. For example, MEDLINE searches on topics such as: muscle relaxation, meditation, isometric exercise (e.g. Wiley et al, 1992), breathing exercise, and stretching exercise reveals many papers which are relevant to Hatha yoga and provide more tangible evidence in support of the claims made regarding the benefits of yoga.

However, to justify the validity of yoga with such a reductionist approach goes against the very nature of yoga as a time honoured holistic science. The best evidence available in support of yoga comes from the millions of people around the world and through the ages who have practiced yoga and continued to practice it because of the positive benefits they obtained.

References

1. Blimkie, C.J., Rice, S., Webber, C.E., Martin, J., Levy, D., and Gordon, C.L. (1996). Effects of resistance training on bone mineral density in adolescent females. Canadian Journal of Physiology and Pharmacology, 74: 1025-1033.
2. Desikachar, T.K.V. (1995). The Heart of Yoga. Inner Traditions International.
3. Feuerstein, G. (1996) The Shambala Guide to Yoga. Shambala Publications: Boston.
4. Iyengar, B.K.S. (1966). Light on Yoga. Schocken Books, New York.
5. Iyengar, G.S. (1983). Yoga a Gem for Women. Allied Publishers.
6. Kannus, P., Alosa, D., Cook, L., Johnson, R.J., Renstrom, P., Pope, M., Beynnon, B., Yasuda, K., Nichols, C., Kaplan, M. (1992) Effect of one-legged exercise on the strength, power and endurance of the contralateral leg. A randomized, controlled study using isometric and concentric isokinetic training. European Journal of Applied Physiology. 64: 117-126.
7. La Perriere, A., Ironson, G., Antoni, M.H., Schneiderman, N., Klimas, N., and Fletcher, M.A. (1994) Exercise and psychoneuroimmunology. Medicine and Science in Sports and Exercise. 26: 182-190.
8. Maier, S.F., Watkins, L.R., and Fleshner, M. (1994). Psychoneuroimmunology. The interface between behavior, brain, and immunity. American Psychologist. 49: 1004-1017.
9. Mehta, S., Mehta, M. and Mehta, S. (1990). Yoga The Iyengar Way. Simon and Schuster: Australia.
10. Norkin, C.C. and Levangie, P.K. (1992). Joint Structure and Function: A Comprehensive Analysis (2nd Ed.). Philadelphia: F.A. Davis Company.
11. O’Connor, P., Sforzo, G.A., and Frye, P. (1989). Effect of breathing instruction on blood pressure responses during isometric exercise. Physical Therapy, 69: 757-761.
12. Ward, B. (1995). Holistic medicine. Australian Family Physician, 24: 761-762.
13. Wiley, R.L., Dunn, C.L., Cox, R.H., Hueppehen, N.A., and Scott, M.S. (1992). Isometric exercise training lowers resting blood pressure. Medicine and Science in Sports and Exercise. 24: 749-754.

General Level Hatha Yoga Sequence for
Australian Physiotherapy Association Conference, at Byron Bay, July 1997

1. Supta Baddha Konasana or Supta Virasana* (5-10 minutes passive supine posture; hips abducted & externally rotated; knees flexed; soles of feet together or * hips adducted & internally rotated; knees flexed)
2. Adho Mukha Virasana (kneeling stretching forward; EOR knee, hip & shoulder flexion; scapulars protracted)
3. Adho Mukha Svanasana (‘downward facing dog pose’ or ‘down-dog’, EOR shoulder flexion; scapulars protracted; 90° hip flexion; hands shoulder width; legs hip width)
4. Uttanasana (standing forward bend; palms flat on floor; EOR hip flexion; knees slightly flexed as required)
5. Virabhadrasana Ia (hip flexor stretch; step L foot back about 1 metre to a lunge; R knee over R heel, finger tips under the shoulders on either side of R leg; EOR extension of L hip; flexion R hip;)
6. Adho Mukha Svanasana (‘downward facing dog pose’; WB on all 4 limbs; hands are shoulder width apart; legs are hip width apart; EOR shoulder flexion & elbow extension; scapulars protracted; up to 90 degrees hip flexion; EOR knee extension)
7. Chataranga Dandasana* (‘push up’ position, or half ‘push up’ with knees on floor with body and shoulders same height as elbows; start pose with straight arms as in the ‘plank pose’ then lower down eccentrically to the ‘push up’ pose; keep shoulders adducted; keep scapulars protracted)
8. Salabhasana* (lie prone, press feet onto floor with knees extended; lift chest off the floor, activating back extensors; keep fingers under shoulders, if possible off the floor)
9. Bhugangasana (‘cobra pose’; lie prone with palms under shoulders; press down with the hands and pull sternum anteriorly and superiorly; depress shoulders; keep the lowest ribs touching the floor)
10. Urdhva Mukha Svanasana* (‘upward facing dog pose’, or ‘up-dog’; lift whole body off the floor except for the dorsum of the feet and the palms of the hands; keep the same shape of the spine as in Bhugangasana and the same back extensor muscle contractions as in Salabhasana)
11. Uttanasana (standing forward bend with palms flat on floor; EOR hip flexion; knees slightly flexed if required)
12. Utkatasana (feet together, half squat; up to 90 degrees hip and knee flexion; EOR arms flexed at shoulder, scapulas protracted)
13. Tadasana (standing up straight; with feet together; arms by the side of the body)
14. Surya Namaskar A X 3 (‘Salute to the Sun’: A smooth flowing dynamic series of postures which may be done in conjunction with the breathing, and which can become very aerobic)
    Inhale (1): From (i) Tadasana take arms up, flexing at shoulders, hip and knees to (ii) Utkatasana;
    then
    Exhale (1): Flex further at hips, bringing palms to the floor to (iii) Uttanasana; extend knees as much as is safe for the lower back;
    then
    Inhale (2): raise head, extend the spine and the elbows, and lift up onto fingers to (iv) Extended Uttanasana;
    then
    Exhale (2): step or jump back to (v) ‘plank’ pose’ and if possible flex at elbows to come to ‘push-up *’ position (vi) (* Chataranga Dandasana); then slide forward to ‘up-dog’ pose (vii) (Urdhva Mukha Svanasana), or ‘cobra’ pose;
    then
    Inhale (3): while still in the ‘up-dog’ or ‘plank’ positionExhale (3): to ‘down-dog’ pose (viii) (Adho Mukha Svanasana) then step or jump the legs between the hands to (ix) Uttanasana

    Inhale (4): raise the head up to (x) Extended Uttanasana;

    Exhale (4): flex elbows; grab ankles with hands; flex knees as requires for lumbar spine safety; and gently flex the neck to bring the chin towards sternum to (xi) Flexed Uttanasana;

    Inhale (5): stand up with knees straight and arms above the head to the half squat (xii) Utkatasana;

    Exhale (5): bring arms down by side of body to (xiii) Tadasana

15. Utthita Trikonasana (‘sideways triangle’ standing pose; feet about 1 metre apart with L foot turned inwards about 20° to R side; R foot turned outwards 90° to R side; move R sitting bone to L side; take R hand to touch R shin; knees extended; R hip flexed and externally rotated)
16. Parivrtta Trikonasana (‘twisted triangle’ standing pose; feet about 1 metre apart with L foot turned inwards about 70° to R side; R foot turned outwards 90° to R side, take L finger tips to floor next to R foot; flex R knee as required; R hip flexed and externally rotated)
17. Virabhadrasana II (sideways lunge pose; feet about 1 metre apart with L foot turned inwards about 20° to R side; R foot turned outwards 90° to R side; trunk erect; R hip flexed and externally rotated; R knee flexed so knee rests directly over the R heel; shoulders abducted; elbows extended)
18. Prasarita Padottanasana AB (standing forward bend; feet about 1 metre apart with both feet facing forward; A: hands on floor between feet; B: hands interlocked behind back; shoulders extended and adducted; scapulars retracted)
19. Parsvottonasana (standing sideways forward bend; feet about 1 metre apart with L foot turned inwards about 70° to R side; R foot turned outwards 90° to R side; palms together behind back; bend forward over R leg with both hips flexing and with anterior pelvic tilt)
20. Utthita Padangusthasana ABC (one leg balance with upper leg knee bent or straight A: pulling opposite leg to chest; B: pulling leg to the side; C: holding leg in front of body with hands on hips)
21. Surya Namaskar A (Do the salute to the sun poses, till the ‘down-dog’ then step or jump to a sitting position for the SITTING POSTURES)
22. Baddha Konasana (sitting pose; spine with normal curvature; hips abducted, externally rotated and flexed; knees flexed; soles of feet together; flexible and experienced practitioners can flex at the hips with anterior pelvic tilt)
23. Upavistha Konasana (sitting pose; spine with normal curvature, hips abducted and flexed, knees extended; flexible and experienced practitioners can flex at the hips with anterior pelvic tilt)
24. Janu Sirsasana* (forward bend with L knee extended; R knee flexed; R hip abducted and externally rotated; bend forwards flexing at hips with anterior pelvic tilt or Simple cross legged forward bend)
25. Marichyasana III (spinal twist with L knee extended and L heel pressing onto floor; R knee flexed and R sole of foot pressing onto the floor anterior to right pelvis; rotate spine to R side; if possible bring L shoulder on the outside of R knee)
26. Parivrtta Janu Sirsasana (2 legs in same position as for Janu Sirsasana; then lateral flexion over straight leg *; or Simple cross legged sideways bend)
27. Dandasana (sit up straight maintaining normal spinal curvature, up to 90° hip flexion; EOR knee extension with straight legs)
28. Paschimottanasana (seated forward bend with EOR hip flexion; some knee flexion if hamstrings are tight or if prone to low back pain; EOR knee extension if hamstrings are very flexible and no low back pain)
29. Malasana (Squatting forward bend with shoulders between knees; hands around outer shins)
30. Bakasana* (from Malasana balance on the arms with knees resting on the upper arms)
31. Ubhaya Padangusthasana (balance on the backside grab the big toes with the first 2 fingers and thumb, extend knees as much as safely possible)
32. Setu Bandha Sarvangasana (backward bending pose with neck shoulders & feet on the floor; hip flexion; some spinal extension; slight posterior pelvic tilt to avoid hyperextension of lumbar spine)
33. Urdhva Dhanurasana* (full backarch on hands and feet)
34. Urdhva Mukha Paschimottanasana (upside down supine forward bend: A: hug knees to chest; B *: grab ankles and try and extend the knees pull the feet towards the face)
35. Jathara Parivartanasana AB (supine twist with A: moving up and down with the breath, i.e. inhale knees to chest & exhale knees to the side, B: move hips to one side & hold knees bent or straight above opposite arm)
36. Supta Padangusthasana D (lying supine; L knee & hip extended; R hip flexed; use hands to pull R leg to chest; keep R knee flexed initially then R knee extended if possible)
37. Parivrtta Padmasana* (Simple twist, in lotus, cross legged, kneeling or any comfortable sitting posture; rotate spine to R with L hand pulling against R knee, R hand resting on the floor behind the body; keep shoulders depressed)
38. Padmasana / Swastikasana / Sukhasana / Virasana (i.e. sitting with erect spine and normal spinal curvature in a lotus pose, cross legged, kneeling, or any comfortable sitting pose)
39. Bramari Pranayama (Breathing exercise while sitting relaxed with erect spine; concentration on making smooth constant humming while making long gentle exhalations)
40. Namaste Mudra (sitting with body and quiet mind; palms together on chest, spine erect and normal spinal curvature; relaxed breathing for a few minutes then bend body forward to relax the spine)
41. Viparita Karani* (semi inverted pose; upper body supine; lower limbs raised off the ground and resting against the wall or with calves resting on a chair (5 – 15 minutes)
42. Savasana* (total relaxation pose, lying supine in anatomical position; or with a bolster resting under the spine or under knees as is most comfortable for the body) (5 – 15 minutes)
43. Dhyana* (meditation) (in Padmasana / Swastikasana / Sukhasana / Virasana) (i.e. sitting in a lotus pose, cross legged, kneeling , or any comfortable sitting pose) (5 – 15 minutes)

Additional Notes to: General Level Hatha Yoga Sequence,
Australian Physiotherapy Association Conference, at Byron Bay, July 1997

• These notes represent only general brief descriptions of a general level sequence of Hatha Yoga poses. For full descriptions of poses an explanations of effects of each pose on the body systems see “Light On Yoga” by B.K.S. Iyengar, and the other yoga texts listed in the References.
• GENERAL: Keep the face and throat relaxed in all the poses. In the beginning always move slowly into and out of the poses. Do not overstrain the body by trying too hard. Initially stay in easiest stage of the poses until you are familiar with their effects. Do all asymmetrical poses on both sides.
• ADVANCED or OPTIONAL POSES: are denoted with a ”, these are difficult variations which should only attempted when the body has developed a sufficient balance between strength and flexibility.
• BREATHING: Breathing should initially be relaxed and normal. Do not hold the breath. As one becomes more familiar with the postures the breathing can become slower and slightly deeper than normal, while not forcing the muscles of respiration and not letting the pressure increase in the head.
• STATIC & DYNAMIC WORK: Each pose has many static and dynamic variations. In the static variations, muscle activity is either isometric or relaxed, and the pose is held for approximately 5 – 10 breaths, or about 30 seconds to one minute. In the dynamic variations, muscle activity is either isotonic, isometric or relaxed, and there is movement in and out of the pose in synchrony with the breath if possible.
• OPTIONAL DYNAMIC LINKING SEQUENCE: A half ‘Salute to Sun’ may be performed between each sitting pose (i.e. lift the body off the ground and go back to the ‘push up’, then the ‘upward dog’, then step or jump back to the sitting pose). This helps ‘counter-pose’ the sitting pose, and it builds on general strength and flexibility, while keeping the body very warm.
• MUSCLE CONTRACTIONS: Isometric muscle contractions should be no more than about 30 -50 % of maximal voluntary contraction to avoid risk of increasing blood pressure. In addition, if the muscles are used synergistically they should be able to take the body into the poses with maximal efficiency but with minimal effort. Once in the poses the muscles should relax as much as possible without losing the basic form of the pose, or the spinal length, and without compromising the safety of any joints.
• SHOULDER STABILITY: Shoulders are best kept depressed and scapulars protracted unless otherwise stated.
• KNEE STABILITY: Quadriceps are usually held in a submaximal isometric contraction in the standing positions. This is either to help stabilise the knee, in which case co-contractions of other knee musculature should be encouraged; or to encourage reciprocal relaxation of hamstrings in hamstring stretches.
• PELVIC & LUMBAR STABILITY: Hold Mula Bandha (i.e. keeping muscles of lower abdomen & perineum gently contracted, and draw the floating ribs posteriorly towards the spine) throughout the poses. Initially this is first learnt on the exhalation and care must be taken not to increase the pressure to head by inadvertently performing a Valsalva manoeuvre.
• SPINAL CURVATURE & LENGTH: Even though many of the poses initially appear to remove the spines natural lumbar and cervical lordosis and thoracic kyphosis, attempts should be made while in the pose to restore this natural curvature. In addition, in ‘forward bending’ poses the practitioner should attempt to lengthen the anterior spine, while the pose itself lengthens the posterior spine. Conversely, in backward bending poses the practitioner should attempt to lengthen the posterior spine, while the pose itself lengthens the anterior spine.
• MODIFICATIONS OF POSES & USE OF PROPS: Many poses are best done with the assistance of a wall (e.g. to hold onto for increased stability), a belt (e.g. to be able to hold onto a limb more easily when flexibility is limited), or a number of other props.
• N.B. All these guidelines are intended for a normal healthy person. People with special musculoskeletal problems or medical pathologies need to practice with all the usual cautions that would be applied for their everyday movement and during a physiotherapy treatment. In certain cases some poses will have to be modified or excluded.
• NB Please do not attempt these poses unless you have attended the classes were the they were taught.
• We recommend that before teaching any of these poses to anyone, that you practice them yourself until you have a firm and personal understanding of their effects.
• Naming & Grouping of Poses: Each pose has a specific Sanskrit name but poses are often named in English depending on which groups they fall into. Examples of common groups of poses are:
  • ‘FORWARD BENDING POSES’: usually involve at least some hip & spinal flexion
  • ‘BACKWARD BENDING POSES’: usually involve at least some hip & spinal extension
  • ‘TWISTING POSES’: usually involve some spinal rotation
  • ‘SIDE STRETCHING POSES’: usually involve some spinal lateral flexion
  • ‘STANDING POSES’: involve standing on at least one leg and perhaps up to 3 more limbs
  • ‘SITTING POSES’: usually have the pelvis in contact with the floor
  • ‘LYING POSES’: are either in supine, prone or side lying
  • ‘INVERTED POSES’: passive or active poses where the part of the body is semi-inverted or inverted so that the effect of gravitational force is reversed
  • ‘ARM BALANCE POSES’: difficult strength building poses balancing on 1 or 2 palms or forearms
  • ABBREVIATIONS:
  • EOR = End Of joint Range of movement;
  • L = Left; R = Right;
  • WB = Weight Bearing; NWB = Non Weight Bearing