How to Support Students With Injuries and Pre-Existing Conditions
by Amber Burke
Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional. Yoga teachers should remain within their scope of practice: This means not attempting to diagnose, treat, or offer medical advice to students.
You’ve asked your students to tell you about their injuries and other pre-existing conditions. They oblige: You soon hear about problems with knees, hips, lower back, wrists—what’s next?
It is not surprising that many general classes include a student, or many students, with an injury or other physical problem; in fact, one in two Americans is affected by a musculoskeletal disorder, a condition or injury that affects the joints, bones, or muscles. And many students come to yoga precisely to address underlying conditions, including musculoskeletal problems.
But as beneficial as yoga can be, not all poses and movements, no matter how carefully they are performed, are safe for those with vulnerabilities (see 10 Myths About Yoga Injuries). Indeed, a University of Sydney study showed that yoga worsened 21 percent of injuries.
Some yoga teachers (and lawyers) think that asking about a student’s injuries increases legal liability: Gary Kissiah, a lawyer, yoga philosophy teacher, and author of books about the law as it applies to yoga studios and teachers, writes, “If a teacher has actual knowledge that a student is injured, the law imposes a duty of reasonable care on the teacher to monitor the student and ensure that he or she does not aggravate the injury.” The suggestions below aim to equip teachers with responsible “next steps” for teaching students who have disclosed injury.
What follows is meant to be general advice to supplement the personalized medical advice students with vulnerabilities should receive from their doctors or physical therapists.
1. Inquire about injuries…and follow up.
Get to class early enough to check in, especially with new students, about anything going on in their bodies—and do this in comparative privacy, instead of in front of the entire class. (Although I have observed teachers being able to create a safe container and solicit medical confessions before the entire class, and somehow it fostered a sense of community.)
An exchange in which you ask students about injuries may not be enough. If they say yes, an important follow-up is, “Have you received a specific diagnosis?” (Certainly diagnosing injuries is outside the scope of a yoga teacher’s responsibility, which is discussed more in #2). If so, ask about any recommendations they received from their doctors about movements they should or should not do.
If their doctor has not given them advice, you could ask if there are any specific movements (in yoga or life) that cause aggravation or are particularly beneficial—for instance, “Can you tell me how that’s been affecting your practice (or the movements you make throughout the day)?” Because newer students may not be prepared for the types of movement they might encounter in yoga, asking, “Has that been affecting your balance?” or, “Has that been interfering with your ability to place pressure on your knees in a hands and knees position?” will help some students to be more specific.
Note that some students will disclose depression, anxiety, or trauma. “Has anything in yoga class been particularly helpful to you?” or “Is there anything I can do to support you throughout class?” are two of the many potential follow-up questions that show your concern.
2. Do not diagnose.
If you ask students about what is going on in their bodies, some may inform you of aches and pains that have not yet been diagnosed. It may be tempting in some cases to offer your opinion about what the problem may be, but do not try to diagnose these problems. You might be right, but what if you’re wrong? There are many injuries and conditions with similar symptoms but very different causes and treatments. All diagnoses should be left to qualified medical professionals. Encourage students who are experiencing pain or other symptoms to consult with a doctor or physical therapist.
3. Co-author a plan of action with your student.
Ideally, conversations about injuries close with a plan of action you and the student develop together. As you think about what recommendations to offer, be wary of any assumptions you might have about the injury or condition; there can be considerable variations in symptoms from individual to individual and as an injury heals or a condition progresses.
Be careful about giving mandates without first taking into account your students’ perspectives. If a student tells you that they have sciatica, osteoporosis, or disc problems, conditions for which deep forward folds are often contraindicated, instead of “Do this” or “Don’t do that,” which can have a silencing effect, consider giving the student a chance to weigh in by asking them something like, “So it sounds like doing deep forward folds and rolling up to stand wouldn’t be a good idea for you?”
If deep forward folds are not right for some students, you can offer an alternative. “Let’s have you skip deep forward folds throughout practice, and instead come into these poses only while keeping a neutral spine,” would be a good suggestion, made even better if you demonstrate what you mean.
Even if you have offered alternatives as part of your introductory conversation, review them as the potentially problematic poses come up throughout the class.
4. Admit the limits of your knowledge.
If you do not know how to keep students with physical limitations safe during practice, and neither do they, just admit it—it’s not your job to know everything, and pretending to know more than you do can be dangerous, causing students to surrender responsibility for their well-being to you in expectation that you will be offering guidance or intervening to minimize risk.
If the injury or condition sounds severe, and this is the student’s first time exercising in a long while, and your class is anything other than extremely gentle, it would probably be best to say something like,“I’d love to have you in class, but would recommend that you get your doctor’s opinion first.”
However, if the condition is clearly not severe, and the student has been exercising regularly, you may simply advise caution: “Honestly, I don’t know much about that, so let’s see how things go today. Perhaps do only half of what you think you can do. Stay aware of anything that does not feel good, and come out of the pose and call me over so we can make it more comfortable or do something else. Let’s both do some research, and I would suggest that you talk to your doctor, so that next time you come to class, we’ll know a little more about how to adjust your practice.”
5. Communicate with your students during and after class.
It’s a good idea for both the student and the teacher to remain tuned in to the injury or condition throughout the practice: Neither can brook the entire responsibility of avoiding injury. Students cannot know every pose or movement that may be harmful for them. They may not feel discomfort in the moment, or the first time they do a pose that may aggravate their condition. On the other hand, no teacher can be expected to know the ins and outs of every diagnosis, and no teacher can be aware of the sensations occurring from moment to moment in a student’s body.
Asking students how poses feel indicates your concern, not your ignorance. Checking in with students throughout class also reminds them to be alert to what they are feeling as they practice.
Check in with students after class as well. Some students may be hesitant to let you know if something didn’t feel right, or to confess that they experienced discomfort during a pose, but if you keep the lines of communication open, you might find that they will share their experiences more readily, and that your teaching improves because of what you learn.
6. Study up.
While you can never be prepared for every potential injury or condition you may encounter, understanding the movements that should be avoided and those that are recommended for the most common musculoskeletal disorders—like lower back and neck pain, arthritis, and bone density losses and associated fractures—will never go to waste.
As you grow more accustomed to the demographic you are teaching, you might notice that certain problems keep popping up, perhaps knee-tracking issues, kyphosis, scoliosis, or sacroiliac dysfunction. If you see a trend, educate yourself about it; if you have a regular student with a specific condition, bone up on it.
7. Apprentice yourself to an expert.
While communicating with your students and doing your own research are valuable, nothing can replace insight from someone who has worked therapeutically with a particular condition. An experienced yoga therapist, physical therapist, or bodyworker may be able to answer your questions about which movements and poses are safe or unsafe for students with particular physical limitations.
Cheater’s guide: You may feel more empowered to ask for a medical professional’s time if you interview them for your article, blog, or podcast!
8. Prepare an inclusive sequence.
Some poses can be easily modified, so keeping suggestions for props and alternative poses in your pocket will help you feel more prepared for a variety of situations. However, what if more than a few poses require modification by more than a few students?
Instead of teaching a class with two “tracks,” you could aim to be as inclusive as possible, tailoring the entire practice to the needs of students with injuries, rather than vice versa. A student without injuries will still derive benefits from such a practice, while a student with an underlying injury or illness may feel excluded by a practice designed for only the healthiest practitioners in the class.
For the benefit of students who have difficulty moving up from and down to the floor, you may want to minimize the “ups and downs” required of the entire class. For the sake of the pregnant student, you may want to teach only prenatal poses to the entire class; the other students will probably never know or mind.
9. Watch your language.
Our teaching language, for instance, when we introduce modifications or variations for students with underlying conditions, can be another playground for our self-awareness and sensitivity.
While some teachers can single out particular students with humor and compassion, and some students don’t mind attention, be aware that naming names in a group setting (“Marta, remember the modification I showed you: Do that instead” or, “Doug, you’re not gonna do this, right?”) has the potential to make some students feel uncomfortable. Many times it might be possible to approach the students in question and speak to them more privately.
Careful language can also construe the decision to modify as praiseworthy: “A smart way to keep yourself safe in forward folds if you have spinal injuries is to work on creating and holding a neutral spine here, in staff pose.” Sharing your own decision to make the same modification validates the choice further: “I’m choosing this version myself today, because it’s giving me a chance to work on lengthening my spine, something I don’t do enough.”
10. Teach an action or theme rather than a complicated “peak” pose.
Some yoga schools counsel their teachers-in-training to build up to a demanding peak pose that requires a high degree of strength and flexibility from students. But it might make more sense to cultivate an interest in the intricacies of seemingly simple poses in students with physical challenges, and skipping, say, bird of paradise, tortoise, and scorpion.
For instance, you could focus throughout the practice on the actions of creating a neutral spine, or tracking the knees well, or distributing weight effectively through the hands and the feet. This way the focus isn’t on the what, but the how, and students de-prioritize “getting somewhere” and instead prioritize a beneficial action.
Some teachers may worry that if they don’t dazzle students with new and difficult poses, class will grow repetitive. However, choosing a theme like the anatomical movements of the breath, the use of a drishti (gazing point), or the qualities of a chakra will make each class feel different even if you consistently draw from a narrower range of accessible poses.
11. Go slowly and encourage mindfulness.
A slow class not only lingers on each pose but slows and instructs the transitions, explaining subtle alignment details and allowing time for students to pay attention to sensation. When teaching students with injuries or other conditions, rather than just saying “Come up to standing” or “Sit down,” it’s important to specify how students are to do these things, step by step, so that students don’t lose their balance, compromise their alignment, or stress a vulnerable area.
12. Speak loudly and clearly.
Speaking up is a matter of safety. Even if you give excellent instructions aimed to keep a student safe during a transition between poses, if those instructions aren’t audible, they are for naught.
Students are going to feel excluded and disengage from class if they can’t hear you. If you are teaching older students, this is especially important. One in three people over 65 has hearing loss, and the majority of yoga injuries occur in those over 65.
13. Be cautious in giving adjustments.
If your students have given you permission to touch them, there may be some poses in which a light touch may help relax them or bring their attention to an area where more engagement is called for. But in some cases, hands-on adjustments may lead to or exacerbate an injury. If students have weak bones, a simple push on the back in a forward fold could cause a vertebral fracture. If a student has difficulty balancing, a touch could be destabilizing and lead to a fall.
When doing adjustments, always keep in mind that it is possible that the student you are touching has injuries they’ve chosen not to tell you about or are themselves not aware of.
14. Balance control and surrender.
The careful balance of control (or abhyasa, “concerted effort”) and surrender (or vairagya, “detachment”) applies to teaching students with underlying problems of any kind.
We teachers absolutely should do our best to prevent students from doing poses that could cause them harm, for example, by saying something like, “From what I understand, it’s safest for those with osteoporosis not to round the spine.” But if the student goes into a deep forward fold anyway, it would probably be inappropriate to yell at them to stop. Whether students adhere to your advice is ultimately beyond your control. (Though you can follow up after class with a reassertion: “This is your practice, but I want to go on the record as saying that I’m a little worried about the long-term effects of that pose on your spine.”)
15. Focus on the positive.
It is a gift to be entrusted with the well-being of another person, but it is also a responsibility, and at times, having conversations about injuries, keeping a close eye on your students, and doing outside research may seem arduous. It may seem like a loss to your teaching not to be able to include in class some of the more acrobatic poses that you yourself can practice and explain with grace.
And, fortunately, over time, as you get to know your students, you may find that fewer conversations and less vigilance are required because you know your students’ abilities and they have become educated in the modifications they must make; that less research is necessary because you keep encountering the same few ailments with which you are now well acquainted; and that you naturally adapt your sequencing and goals to the needs of your students, easily separating the poses you yourself practice with abandon, and the poses you teach in a mixed class.
Your attentiveness to teaching students with underlying conditions and injuries is valuable: It creates space for students who might not have been sure they could do yoga, or who have felt uncomfortable in fast-paced classes taught by teachers who may have been less solicitous.
Your work may even deepen your respect for the intricacies of all bodies, and for yoga, which can accommodate such diverse needs.