Published in INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 17 (2007) 121
Yoga and Multiple Sclerosis:
A Journey to Health and Healing
written by Eric Small and Loren Fishman, M.D.
Demos Medical Publishing, 2007. Paperback, 296 pages. $21.95.
Reviewed by Karen O’Donnell Clarke.
As a person with multiple sclerosis and a Yoga teacher, I have been eagerly awaiting the publication of Yoga and Multiple Sclerosis: A Journey to Health and Healing, the first book to address Yoga specifically for people who have multiple sclerosis. The book includes âsanas adapted for individual needs and medical explanations for how Yoga works to reduce symptoms and improve function. According to the authors, the intended audience for this book includes people who have mild or severe multiple sclerosis, family members, Yoga teachers, and the medical community.
Eric L. Small was diagnosed with multiple sclerosis more than 50 years ago. As the book says, “In the past fifty-four years since he was diagnosed with MS, Yoga has enabled him to maintain a life that sometimes surprises even him.” For the past 25 years, Small has used his knowledge of Yoga and multiple sclerosis to develop Yoga programs for students of all levels of mobility and ability. He created the video Yoga with Eric Small: Adapted for People with Multiple Sclerosis or Other Disabilities for the Southern California Chapter of the National Multiple Sclerosis Society. Dr. Loren M. Fishman, co-author of the book Relief is in the Stretch and Assistant Clinical Professor in Rehabilitation at Columbia College of Physicians and Surgeons, has spent the last 25 years using Yoga in his medical practice and adapting it to the needs of his patients. Both authors are trained in the Iyengar tradition, and throughout the book, they pay homage to their revered teacher, Mr. B.K.S. Iyengar.
The book is divided into two parts: (1) “Yoga for People with Multiple Sclerosis” featuring Eric L. Small, and (2) “Function-Directed Yoga for Functionally Impaired Individuals” featuring Loren M. Fishman, MD. The preface, co-written by the authors, seeks to contextualize the ancient practice and teachings of Yoga with contemporary science and Western culture. In this section, the authors offer a clear and easy to understand description of the intent and practices of Yoga as codified in Patanjali’s Yoga Sûtras. While this book focuses mostly on âsana, the authors make clear that Yoga is a comprehensive system that continues to evolve.
Part 1 contains seven chapters focusing on âsanas, including: Restorative Series, Wheelchair Series, Chair Series, Seated Poses, Seated/Floor Series, and Prânâyâma and Relaxation. This section offers a “straightforward but gentle introduction to Yoga for people with significant MS involvement.” The authors suggest that “each Yoga session should include some poses from most of the sequences” with the recommendation that “a family member, friend, or a certified Iyengar Yoga instructor may be required to help you in certain poses.”
Each pose is named in Sanskrit and English and has detailed instruction guiding the practitioner into poses. The book includes step-by-step photos of Eric Small performing the various adaptive poses, and describes the benefits of each pose. Small’s experience and dedication to the Iyengar method are obvious as he guides the practitioner into proper alignment using props to modify traditional poses. Along with the procedural, step-by-step approach to the poses, Small also shares heart-felt reflections on the subtle benefits of Yoga for MS drawn from his own experience.
For Yoga teachers who are not trained in the Iyengar tradition, Part 1 offers creative and practical adaptations to traditional Yoga poses. An important feature in Part 1 is the author’s attention to safety. For example, he uses the wall to provide extra support or to control poses in which slipping could be a hazard, such as chair-supported back-bend (viparita dandâsana) and chair-supported extended triangle pose (utthita trikonâsana). Another way that Small creates safety is by using multiple chairs to bring the floor up to the student, for example, using three chairs to accomplish head to knee pose (janu sirsâsana). This is particularly important for students who are at risk of falling due to challenges with balance and muscle control. It’s been my experience that for many students who have multiple sclerosis, a teacher or helper is essential for many poses, particularly restorative poses. Small recommends “that a Certified Iyengar instructor with an Intermediate Junior 2 or above certificate be consulted and present when” supported shoulderstand is attempted.
Part 2 contains seven chapters that focus on common symptoms and the benefits of Yoga to people who have multiple sclerosis, including: Reduce Fatigue, Improve Range of Motion, Spasticity, Strength, Coordination and Balance, Confidence and Calm, Advanced Balance, and Breathing. Throughout the chapters in Part 2, the reader learns something about anatomy and about how Yoga works. For example, in the chapter on spasticity, the author provides an explanation of the stretch reflex and how it can be used to reduce muscle spasticity, a common problem for people who have MS. Fishman also builds a case for the benefits of Yoga by discussing brain plasticity and integration, and includes rehabilitation theory on how motivation determines the success of a course of action.
The types of MS are discussed, but not the pathology or the fact that MS is a disease of the central nervous system. For the benefit of Yoga teachers and others who are not familiar with this disease, stating that MS is a disease of the brain and spinal cord, not the muscles, might add clarity as to neurogenic versus musculoskeletal causes. What I particularly liked was how Fishman distinguished impairment, disability, and handicap. “In rehabilitation medicine people often distinguish impairment, the loss of or injury to living tissue through amputation, stroke or illness, from disability, being incapable of performing basic tasks such as dressing, bathing, walking, and both of these from handicap, losing the capacity to fulfill common roles in society such as parent, student, employee.” Fishman goes on to say, “Yoga’s major role in both forms of MS, where impairment is not much under control, is to limit disability and thereby reduce handicap…It may reduce impairment.” This statement provides a goal and mission for Yoga teachers who work with students who have physical impairment.
Part 2 also includes many poses and sequences, and each pose is shown in three forms. The “classical pose” is given first for students with “the least MS involvement.” According to the author, “They are also valuable for those who cannot perform them at present…for these individuals, getting an idea of what lies ahead…can be conceptually important and a source of inspiration.” Next comes the entry-level pose for students with “restricted function and for those who might face Yoga with reservations.” The intermediate pose, intended as a transition from the entry-level pose toward the classical pose, is placed last in the sequence.
After reading the author’s explanation for this order of forms, I understand his rationale, but I disagree with this approach. For students who have serious impairment and possibly permanent disability, I would prefer to see a developmental approach that starts with the entry-level version and ends with the classical version. For example, in Chapter 7: Reduce Fatigue, the student is guided first into the classical version of upward facing bow (urdhva dhanurâsana, which many Yoga practitioners would recognize as “the wheel”). In Chapter 8: Improve Range of Motion, the first photos are of triangle pose (trikonâsana) in the full expression with hand to the foot. In my experience, these versions, especially in good form, are ambitious even for students who don’t have physical challenges.
While the author admits that “many people with severe multiple sclerosis might consider the last few pages on a par with Alice in Wonderland. But the first step is half the journey…,” some of the photos in Part 2 depict poses that are too challenging for the average student with no symptomology. Even with the many precautions throughout the book advising the practitioner to approach the postures gradually, except for the entry-level poses, I can’t help but think that the chapter, Advanced Balance, belongs in another book. The photos are beautiful, but most of my students who have MS struggle to stand, making even the entry-level postures difficult. Photos of people who have various physical challenges modeling the poses in proper alignment based on their abilities would have been more inclusive and more meaningful as well.
Several other photos, including the cover photos, show what I would consider advanced versions of the postures for many beginning and experienced Yoga practitioners. For example, many of my students who don’t have MS struggle with placing the foot high on the thigh in tree pose (vrksâsana). Students who have MS often experience muscle weakness, spasticity, or difficulty with balance that would preclude placing the foot higher than the ankle or calf. Except for one photo on the cover depicting a wheelchair version of a backbend, the cover does not imply that this is a book about adaptive and therapeutic Yoga for people who have a chronic and often disabling health condition.
This book has also reminded me of the importance of language. The word “patient” is used repeatedly to describe people who have multiple sclerosis. As a person who has MS, I don’t consider myself an MS patient. Nor do I “suffer from MS.” It’s a small thing, but Yoga is about the individual. Labeling diminishes. I have asked students who have lost function from MS what they think about the phrase “MS sufferer” or “suffers from MS.” None of them think of themselves that way.
Despite these concerns, Yoga and Multiple Sclerosis: A Journey to Health and Healing will be a must-have book. For people who have MS, this is the first book that addresses Yoga for MS. It offers hope, inspiration, adaptive practices for all levels of mobility and ability, and reasons why Yoga works for particular symptoms. For Yoga teachers, this book offers valuable practices and insights that teachers can use to make Yoga accessible and appropriate for students who have multiple sclerosis and other health challenges. For the medical community, this book offers great visuals for adaptive Yoga postures and explanations for how Yoga works, from a peer with years of experience in the field of rehabilitation.
Karen O’Donnell Clarke is a Yoga teacher and Yoga therapist in Ledyard, CT with advanced training from Kripalu Center for Yoga and Health and Integrative Yoga Therapy (IYT). She created Teaching Adaptive Yoga for Multiple Sclerosis as continuing education for Yoga teachers and healthcare professionals who are interested in offering Yoga to students who may have limited access or ability to attend traditional Yoga classes. www.yogahealsus.com.