When to Refer Out

Lesson Overview

In this lesson, we provide specific situations in which it’s advisable to refer a student out for assessment before participating in a group class.

Objective

Know when it’s advisable to refer students out for diagnosis or individual assessment and how to be prepared to do so.

Description

Describe a way to lessen the likelihood that students will attend a class that is not a good fit for them. Describe six symptoms that may indicate a need for immediate medical care. Name five conditions for which it’s advisable to refer students to work individually with an expert before attending a group class. Describe three ways to respond to students who are experiencing a condition outside the teacher’s qualifications and experience. Describe the questions students need to ask their healthcare provider in order to guide decisions about safely practicing yoga in the case of surgery, injury or serious condition.

Before Students Arrive

Helping Students Make Informed Decisions

We recommend that you offer guidelines to help students and potential students make informed choices about which classes they choose to attend. By sharing detailed information ahead of time, you can help to prevent students arriving at a class that is not a good fit for them.

The places where such information can reach potential students:

  • Yoga studio (or other facility) website
  • Teacher website
  • Brochures and signage at the yoga studio or other facility
  • Front desk staff or anyone who interacts with students on the phone and at the teaching site

Consider which classes are a good fit for students with injuries and conditions, and which are not.

  • Is the class style vigorous and/or does it involve quick movements?
  • Does the class usually get a large number of students making it difficult or impossible for the teacher to attend individually to all students?
  • Is it taught by a relatively new teacher, or one who is not comfortable offering adaptations for various conditions?
  • Is it taught by an experienced teacher who has demonstrated capability in safely accommodating various conditions?
  • Does the studio have plenty of props to meet the needs of students with injuries or conditions?
  • Does the studio as a whole cater to a student base that is focused on achievement-oriented asana?

Sample Content

Consider verbiage for studio and class descriptions that can help students appropriately self-select. For example:

  • Prerequisites: completed the intro series or equivalent experience; knowledge of how to make personal accommodations.
  • All experience levels welcome; accommodations offered.

While such basic class descriptions may be helpful, more effort to guide students with injuries and conditions is advisable. Here are some ideas to get you thinking:

Sample Content for Pregnant Students

Are you expecting? Congratulations! Please check out our prenatal class, taught by our wonderful, specially trained teachers, where you can energize and relax in a class designed to address your various needs during each trimester.

Thinking of attending a general drop-in class instead? Please attend at least one prenatal class first to get a sense for how you may wish to personally accommodate the needs of your growing baby when in a general class.

And please be sure to inform the teacher of your pregnancy and experience before class starts.

Sample Content for Students with Injuries

Are you suffering from a serious injury or recent surgery?

Yoga can help! From breathing and relaxation practices to mindful movement, yoga offers profoundly effective resources for students recovering from a vast variety of injuries and conditions.

But each person’s circumstances are unique, and it’s important to know your particular contraindications, limitations and any other specifics related to your situation. This way, you can focus on practices that optimally support where you are now.

So before dropping into a group class, please be sure to schedule a private consultation.

If you have a diagnosis and have been cleared to practice, contact us for a list of excellent yoga therapists and teachers who you can call for an individual consultation prior to joining a group class. You can learn at your individual session how to safely accommodate your condition in a group class.

If you don’t yet have a diagnosis, select this link for some questions you may wish to ask your provider. (See below for sample questions to ask a healthcare provider.)

When to Refer Out

Basic Considerations

  • No matter the injury or condition, be sure to ask about the student’s personal knowledge of her situation along with any professional diagnosis or recommendations.
  • It is the teacher’s responsibility to encourage students to share information about their individual situation.
  • Please give students the opportunity to speak privately to you. This can be as simple as coming up to her mat or stepping to the side of the room.
  • Please be sure to give students express approval to make any necessary accommodations.
  • Please also give students a safe resting pose for their situation and permission to stop practice if they have any concerns.
  • In some cases, such as after a recent surgery, it’s vital that students work individually with a physical therapist, yoga therapist, or other qualified professional prior to engaging in a group class.

An Imbalance vs. a Pathological Process

Yoga therapist and expert A.G. Mohan (in Yoga Therapy 2004, p 172) explains that aches and pains can come from two primary causes which he terms “structural” or “pathological.”

  • What he calls “structural” we might also think of as an imbalance. These are conditions that arise in “otherwise healthy people.” This includes imbalances in strength, flexibility and alignment and is often brought on by overuse, lack of use or improper use of particular body parts. Often, typical yoga modalities are well-designed for such cases.
  • A different situation is what he terms an “underlying pathological process.” Examples include degenerative and autoimmune conditions such as osteoarthritis and rheumatoid arthritis. In such cases, it’s advisable to refer students to a yoga therapist or other expert before attempting to accommodate them in a group class.

Refer Students with These Conditions

Alison Trewhala of “Yoga for Healthy Lower Backs” recommends that any student that suffers from the following symptoms (drawn from The Back Book) should see a medical doctor:

  1. Severe pain that gets worse over several weeks rather than better, or that is causing a state of ill health (to check for infections or cancerous tumors)
  2. Difficulty passing or controlling urine
  3. Numbness around the inner thighs, genitals or rectum
  4. Loss of control or feeling around the rectum
  5. Numbness, pins and needles, or weakness in both legs
  6. Unsteadiness on the feet

Expert Baxter Bell MD suggests that these specific conditions be addressed in gentle classes, restorative yoga or by teachers particularly talented in these areas:

  1. Chronic fatigue syndrome
  2. Active multiple sclerosis
  3. Post-chemotherapy
  4. Severe rheumatoid arthritis
  5. Lyme disease

Getting a Diagnosis & Personal Plan

As a reminder, yoga teachers—and even yoga therapists—are not trained or licensed to diagnose injury, illness or disorder. You may wish to be very clear about this point as needed and be sure to ask students if they have obtained a diagnosis.

In addition, with post-surgery or other serious conditions, students need to work individually with an expert to learn how to safely practice in a group class.

AVOID MAKING SELF-DIAGNOSIS

I certainly understand the reluctance of many to go see a doctor when you may not have health insurance, or have a plan that covers very little of the cost that might be involved in finding out what is going on. But a delay in finding out what is going on or making an incorrect self-diagnosis could leave you worse off in the long run and cost you even more. – Baxter Bell

SOME CASES REQUIRE AN INDIVIDUALIZED ASSESSMENT

As a physical therapist who’s been practicing for forty years, I would not want somebody with a recent hip surgery to arrive at my class, expecting me to give them a personalized program. In order to do that, I would need an extensive individual session to take their medical history, evaluate their condition, check their range of motion, and read their surgery report. This simply isn’t something that can be done in a group class setting… Ideally, after a patient has had a major injury or surgery, they need to be referred to professional physical therapy or rehab to help them understand what they should and shouldn’t do to best facilitate their body healing. Unfortunately, many people are not receiving that extensive care, and desperate for help, start seeking yoga classes. Yoga teachers are put in a challenging situation because they want to help the student, but often don’t have the necessary training, experience, or time when teaching a group class to do so. – Julie Gudmestad

How to Respond

Be Prepared

First, reach out to people in your community in order to develop a contact list for qualified experts.

  • At minimum, have contact information for yoga therapists.
  • You may also wish to include physical therapists, naturopaths, ayurvedic doctors, psychotherapists or other professionals.

Responding to Students

If you are a new teacher and not yet confident in teaching to students with particular conditions, please see Injuries & Conditions: How to Prepare as a Teacher for some steps that can help you gain more expertise and confidence over time.

Meanwhile, do you know how to respond to situations outside your qualifications and experience?

Baxter Bell MD offers some excellent advice including these options:

  1. Be honest. Explain that you are not well versed in this issue. Invite the student to take class if she is comfortable in assessing when to adapt.
  2. For students who have been practicing with their condition, you may wish to ask them to share the recommendations from their health team, describe their physical restrictions, and ask if they have learned any modifications from other yoga teachers. “The new teacher then gets an on-the-spot tutorial and may feel much more willing to have the student participate in the day’s class!”
  3. Explain that you don’t know specifically what to offer the student today but that you will look up the condition and have some options available next time. Encourage her to skip class today, reiterating that you are most interested in giving her as safe and beneficial an experience as possible.

Questions for Healthcare Provider

The following excellent questionnaire is from Yoga for Healthy Aging. You may wish to have it on your website and at your class location to provide to students who have a condition or injury. Please provide attribution: Yoga for Healthy Aging.

QUESTIONS FOR HEALTHCARE PROVIDER BY YOGA FOR HEALTHY AGING

If you have had a surgery, or if you have a medical condition or an injury, you should explicitly ask your doctor or physical therapist which physical actions are safe for you and which are not safe…

  1. Can I go upside down?
  2. Can I round my spine forward, backwards, or side to side?
  3. Can I twist my spine?
  4. Can I cross my legs?
  5. Can I put pressure on this or that part of my body, such as my knees or wrists?
  6. Can I stand on one leg?
  7. Can I practice in bare feet?
  8. Is my recovery from a serious illness like cancer at a place where I can safely increase my physical activity?
  9. Is it safe for me to do a vigorous practice where I am sweating and exerting myself? Is it OK for me to hold standing poses for long periods of time that require endurance and strength?
  10. Is it all right to stretch an injured tendon, ligament or muscle now?
  11. Would any of the medicine I am taking interfere with my practicing-by making me dizzy, unfocused, distracted, off balance or sleepy?
  12. If I am recovering from a contagious illness, am at risk of spreading my illness by attending a public class?
  13. How long should I wait before returning to class or home practice? After surgery, how long do I wait before it is safe to stretch the area where my incision or scar is? If I have had a joint replacement or repair, such as a hip or knee, is there a limit to my range of motion in certain directions that I should honor?