Yoga as a Therapeutic
in Primary Care
Oct 14, 2016
Zahra Bardai
BSc MD CCFP (COE) MHSc FCFP RYT
DISCLOSURES
FACULTY:
Dr. Zahra Bardai BSc MD CCFP (COE) MHSc FCFP RYT
RELATIONSHIPS WITH COMMERCIAL INTERESTS:
Grants/Research Support: None
Speakers Bureau/Honoraria:
Purdue Pharma Canada
Merck Canada
Pfizer Canada
Biovail Corporation (Science and Medicine
Canada)
Kinetic Konnection
Consulting Fees: None
Other:
Pri-Med Planning Committee
IHS Reviewer
DISLOSURE of
COMMERCIAL SUPPORT
This program has received NO financial
support
This program has received NO in-kind
support
Potential for conflict(s) of interest:
NONE
MITIGATING
POTENTIAL BIAS
This session will focus on best
available evidence for information
presented
Opinions of the speaker will be
identified as such
MITIGATING
POTENTIAL BIAS cont.
OBJECTIVES
Physiology of Yoga
To introduce key concepts of yoga practice:
Breath
Posture
Stillness
To review the physiology behind the
concepts of yoga and the science that
supports it
To apply the key concepts of yoga to clinical
practice
To discuss the practical considerations in
prescribing yoga as a therapeutic in primary
care
DEFINITIONS…
A discipline which includes
breath control, simple
meditation, and the adoption of
specific bodily postures as
practiced for health and
relaxation
KEY YOGA
CONCEPTS
Breath
Posture (Asana)
Stillness
FOUNDATIONS…
BREATH
Physiology
of Breath
Respiration is divided into 4 major
functional events:
Pulmonary ventilation
(air in and out between the atmosphere and the lung)
Diffusion of O2, CO2
(between alveoli and blood)
Transport of O2 and CO2
(between blood and tissues)
Regulation of ventilation
(multifactorial)
-Textbook of Medical Physiology
Guyton and Hall 9th edition
Pulmonary
Ventilation
Diffusion
and
Transport of
O2 & CO2
Acid Base Metabolism
Relative to Breath
Accumulation of CO2 in the blood
affects blood pH
Blood pH influences amount of O2
available for tissue diffusion and use
Lungs release waste CO2 (acid) from
cellular metabolism
Immediate regulation of acidity or
alkalinity of blood by increasing or
decreasing the speed and depth of
inhalation and exhalation
Transport of
O2 , CO2 and O2 disassociation curve:
the Bohr
Effect
The more CO2 present
in the blood the more
readily hemoglobin
releases O2 to the
tissues
Pranayama…
Yogic Breath
Cornerstone to yogic practice
Vital force
Usually involves decreasing RR by
elongation of inhalation and
exhalation
Pranayama…
Yogic Breath
Used to cool, or heat up the body
Assists in releasing muscular tension
in the asanas (poses)
Used as a cue (biofeedback) to achieve
ease in a posture
Focuses the mind (mindfulness)
Assists in relaxation
Pranayama…
Yogic Breath
Dirga ( 3 Part Breath)
Ujjayi (Ocean Breath)
Inhalation/Exhalation
patterning
e.g. 4-7-8
Sithali
Kapalabhathi
Nadhi Sodahana
The Muscles of
Pranayama
Pranayama occurs by engaging the
primary, secondary and accessory
muscles of respiration
Diaphragm
Intercostals
Abdominal muscles “core”
Pelvic floor muscles “pelvic
diaphragm”
Vocal chords/glottis “vocal
diaphragm”
Yoga Anatomy -Kaminoff and Matthews
1st Edition
Applying Physiology
to Yogic Breath
Dirga breath potentiates full use of IC
Ujjayi breath potentiates full expulsion of
ERV
Together improves use of VC
Slowing down the RR induces hypercapnia,
mild respiratory acidosis that shift the O2
hemoglobin disassociation curve to the right;
increasing the tissue availability of O2
Secondary effect of conditioning the primary
and secondary muscles of respiration
Pranayama…
Case Vignette
39 yo woman, self described as “high
strung” and a “worrier”
Married mother of 2 boys ages 7 and
10.
Neg psychiatric history.
Recent knee injury (degenerative
meniscal tear, treatment with medical
management and physical rehab on
STD) has stretched coping ability.
Pranayama…
Case Vignette cont.
Younger son with history of febrile
seizures (last one 4 years prior),
Son with witnessed seizure on
weekend requiring EMS
intervention- no complications, now
asymptomatic on appropriate
medical management and specialist
care
Seen in office Monday for follow up
and you walk in on her having an
acute panic attack:
hyperventilating, fearful, pressured
tangential speech, tremors
Pranayama…
Case Vignette cont.
Immediate management
options for panic attack:
a. SL lorazepam
b. Get her to breath into a
paper bag
c. Pranayama breath exercise
d. Shock her by slapping her
across the cheek
FOUNDATIONS…
POSTURES
Muscle Physiology
Muscles used in Yoga Postures
Skeletal (voluntary)
Smooth (involuntary)
Cardiac (involuntary)
Skeletal muscular movement is the
culmination of multi-system
mechanisms resulting in muscle
contraction that can hold, shorten,
or elongate a muscle in a stable
position
Types of Muscular
Contractions
Isometric
on contraction the muscle does
not shorten or lengthen
Concentric
on contraction the muscle
overcomes resistance and the
muscle shortens
Eccentric
on contraction the opposing
force on the muscle causes it to
lengthen under tension
Isometric Contraction Concentric Eccentric
Contraction Contraction
( + isotonic) (- isotonic)
ACTION Holding Stability Shortening Lengthening
(static) (dynamic) (dynamic)
OUTCOME Increases strength of Muscle contraction Slow, controlled
muscle quickly against a load or contraction with
external force; muscle elongation
increases muscle against a load;
mass Strengthens muscles
and provides the
“brakes” to protect
joints
INDICA- Can be used to minimize Used to increase Rehabilitate
TIONS muscle atrophy in muscle strength; tendinopathies; can
immobilization; used early improves endurance be done with or
in rehabilitation for and power of a without resistance
activation of isolated muscle (e.g. Achilles
muscle groups tendinopathy with
drop heel exercises)
Fascial Physiology
STRUCTURE:
dense irregular connective tissue
that surrounds and connects every
muscle, and every single organ of
the body forming continuity
throughout the body
Important integrative element in
human posture and movement
organization
Schleip, R. J Bodyw Mov Ther 2003;7(2):104-116
FUNCTION:
Referred to as the “organ of form”
or “mechanical matrix”
Fasciae transmits muscle force and
used in load bearing functions
FUNCTION cont.:
Fasciae used as elastic spring for
oscillatory movement such as
walking, hopping or running when
supporting skeletal muscles contract
isometrically
When impaired (injury, FM) there are
deformations in fascial stiffness and
possible tearing.
Schleip, R. J of Musc Pain 2010 18(4): 393-395
Yoga and the Fascia
“lengthening of the muscle
and fascia in the context of
identifiable biomechanical
based core movement
pathways is an effective
way to restore both
structural and functional
integrity”
DellaGrotte J et al J Bodyw Mov Ther 2008 12; 231-245
The Yoga Bandhas
aka Muscular Locks
“Body Locks” Pivotal in Asana
Practice
Mula Bandha - engagement of the
perineum
Uddiyana Bandha- engagement of
the abdominals and “core”
Jalandhara Bandha-engagement of
the head and neck muscles
Picturing the
Bandhas…
Engaging the Bandhas…
The Key Muscles of Hatha Yoga -Ray Long 3rd Edition
APPLYING
MUSCULAR/FASCIAL
YOGA CONCEPTS :
Warrior II POSE
ISOMETRIC
Core
CONCENTRIC
Hip Flexors
ECCENTRIC
Hip IR
Hip Adductors
FASCIAL
ENGAGEMENT
Spiralic Turning
Yoga Anatomy -Kaminoff and Matthews 1st Edition
Posture…
Case Vignette
27 yo man, self employed IT specialist
x 5 years
Spends 8-14 hours/day on the
computer mostly from home
Experiencing neck pain and burning
between the shoulder blades x 6
weeks
Neg medical history
No rx medications
Takes prn dosing otc ibuprofen- helps
a little
Posture…
Case Vignette
On examination significant findings
are:
Turtle neck posturing
(head forward, ears in front of shoulders,
with an exaggerated anterior curve in the
lower cervical vertebrae and an
exaggerated posterior curve in the
upper thoracic vertebrae leading to
lordosis lower cervical spine
K kyphosis upper thoracic vertebrae)
Periscapular tender points bilaterally
Posture…
Case Vignette
WHAT ADVICE WILL YOU GIVE HIM
ON POSTURE?
In the sitting position, starting from the bottom,
the feet should be placed on the ground (or foot
rest if they don’t reach), hip distance apart with
the weight distributed evenly.
Legs should be uncrossed. Knees should be bent at
a 90-degree angle, and positioned at the level of
your hips. The pelvis is kept in a neutral position
(avoid tilting).
The back is long (imagine rising up through the
crown of the head), and the stomach muscles are
slightly engaged by bringing the navel closer to the
spine.
Shoulders are brought back but not so much that
the back arches. Allow the arms to rest on the
table making sure that the forearms are positioned
parallel to the ground.
Lastly, to position the head, the chin is brought
slightly down toward the chest and the ears lined
up over the shoulders.
http://www.goodnewstoronto.ca/2014/06/the-dos-of-
proper-posture-sitting-and-standing/
FOUNDATIONS…
STILLNESS
Mindfulness
“The awareness that emerges
through paying attention in a
particular way, on purpose,
in the present moment and
nonjudgmentally to the
unfolding of experience
moment by moment”
Jon Kabat-Zinn 1994, 2003
“dispassionate, non-
evaluative and sustained
moment to moment
awareness of perceptible
mental states and processes”
-Grossman et al 2004
“a receptive attention to and
awareness of present events
and experience”
-Brown et al 2007
Yoga Stillness
“Yoga is the cessation of movements
in the consciousness”
Pantajali, Sutra 1.2 ~200BC
“Yoga is defined as a restraint of
fluctuations in the consciousness.
[It] is the art and science of mental
discipline”
BKS Iyengar
Light on the Yoga Sutras of Patajali
1966
Comparing Components
MINDFULNESS YOGA STILLNESS
Self regulated attention Clearing and quieting of mental
chatter
Moment to moment awareness Being present in the moment
via meditation techniques
Observation and acceptance Letting go of non-serving
without trying to change or preconceptions “acceptance and
judge surrender”
Enhancement of personal Bringing awareness to the body
engagement with a resultant and breath
experience of flow (optimal
psychological state)
Neurophysiology of
Mindfulness
NETWORKS TO CONSIDER:
A. Default network
ventral cortex
automatic self evaluative
primitive emotional thinking
continuous cycling of thought
self reinforces
self attribution of external event
“negative narrative sticks”
Neurophysiology of
Mindfulness
B. Attentional network
Pre/frontal cortex, parietal cortex,
thalamus, temporal parietal
junction, frontal eye fields,
colliculus, anterior cingulate
cortex, lateral ventral cortex, basal
ganglia
subdivided into alerting,
orienting and executive control
networks
Neurophysiology of
Mindfulness
C. Salient network
dorsal anterior cingulate,
ventrolateral prefrontal cortex,
anterior insula
attentional control function of
relevant immediate stimulus
activation of salient network:
activation of default network
redirects/redeploys default network
signals executive network to act
Bottom Line:
Paying attention in the
moment changes the way the
brain thinks
Awareness of a stimulus,
without engagement leads to
acceptance
“ Notice what you
notice and let it go”
Malinowski, P. Frontiers in Neurosc 2013; 7:8
The story of the ice cream cone
and the raisins
The Key Muscles of Hatha Yoga -Ray Long
3rd Edition
Human physiology, body kinetics and
neural plasticity literature supports yoga
principles of Breath
Posture
Stillness
Recommending Yoga...
Yoga is Indicated in…
Chronic LBP (mechanical) Stress
Sciatica (Piriformis) Anxiety/Depression
Osteoarthritis Insomnia
Rheumatoid Arthritis Chronic pain
Tendonitis Pre/Post Natal care
Pelvic Floor Dysfunction Diabetes
Fibromyalgia Hypertension
Chronic headache (tension) Obesity
Concussion Cancer support
Caveats…
Variety of Yoga styles, intensities and
durations used in studies, however,
different styles studied follow similar
principles and no one was found to be
superior.
Yoga’s emphasis on strength,
flexibility breathing and focused
awareness may be more important
than specific type of yoga
User factors- i.e. use of postures,
breath work, intrinsic motivation,
user expectations
Instructor factors- i.e. style, focus,
training
Intrinsic study limitations
Can Yoga be Harmful?
Cramer H, Krucoff C, Dobos, G. Adverse Events
Associated with Yoga: A Review of Published
Case Reports and Case Series. PLOS ONE Oct
2013 (8):10 e75515 www.plosone.org
35 case reports and 2 case series (total 76
cases)
RESULTS:
10 cases had medical preconditions,
mainly glaucoma and osteopenia.
Pranayama, hatha yoga, and Bikram yoga
were the most common yoga practices;
headstand, shoulder stand, lotus position,
and forceful breathing were the most
common yoga postures and breathing
techniques associated with injury.
Of the 76 adverse events:
27 msk
14 nervous system;
9 eyes.
15 full recovery
9 partial recovery
1 no recovery
1 died.
Study Conclusions
“As any other physical or mental practice,
yoga should be practiced carefully under the
guidance of a qualified instructor. Beginners
should avoid extreme practices such as
headstand, lotus position and forceful
breathing [kapalabathi].
Individuals with medical preconditions should
work with their physician and yoga teacher to
appropriately adapt postures; patients with
glaucoma should avoid inversions and patients
with compromised bone should avoid forceful
yoga practices.”
Do Mind-Body Practices
Affect Health Care
Utilization?
Stahl JE, Dossett ML, Lajoie AS et al.
Relaxation Response and Resiliency Training
and Its Effect on Healthcare Resource
Utilization. PLOS One Oct 2015
http://dx.doi.org/10.1371/journal.pone.0140212
Retrospective Study (use of Research Patient
Data Registry)
n=4453 intervention group
n= 13 149 matched control group
Intervention:
relaxation response and resiliency
training (3RP): meditation, mindfulness,
social support, cognitive skills training,
+ve psychology to reduce stress response
RESULTS:
43% reduction billable
encounters (outpt, urgent
care, ER, hospitalizations) for
intervention group in all
functional and clinical
encounter categories (
p<0.0001)
Rough estimated average cost
savings of $1500 - $60
200/pt/year (US)
Yoga is grounded in
accepted medical physiology
Yoga has clinical application
for many common medical
conditions
Yoga has a low rate of
adverse events
Yoga can reduce health care
utilization and thus health
care costs
Writing a “Yoga Rx”
No evidenced consensus
Exercise prescription
literature and current
practice standards in
counseling PA
/recommending physical
rehabilitation
PA GUIDELINES FOR CANADIAN
ADULTS
150min/week
Bouts of 10min
MOD-VIGOROUS INTENSITY
AEROBIC PA
Muscle & bone strengthening
2 days /week
65+ yrs add activity that
enhances balance and
prevents falls
http://www.exerciseismedicine.ca
What Style of Yoga to
Recommend?
All yoga styles involving
physical postures are
derived from Hatha Yoga
Common Western Styles…
Anusara Iyengar
Ashtanga Kripalu
Bikram Viniyoga
Moksha Sivananda
Vinyasa/Power Yin
Kundalini Restorative
Yoga Therapy
Individual approach
Functional recovery focus
Based on breaking down yoga
postures, progressive movements and
breath work
Use of props for adaptation and
progression
Achieving emotional, psychological or
physiological goal of the individual
Finding a Yoga
Therapist
IAYT
International Association of Yoga Therapists
Accreditation of yoga therapy
training programs
Voluntary Registry
http://iayt.site-
ym.com/search/custom.asp?id=11
56
Increasing number of PT/RYT
offering yoga therapy
Alternative Yoga
Resources…
Referring to “non-athletic” styled
yoga studios
Finding established studios with
beginner foundation classes
Specific Studio Introductory offers
Passport to Prana
https://www.passporttoprana.com
Take Home Message
Yoga’s positive outcomes in
the treatment of chronic
disease management can be
attributed to improved core
strength, stabilization,
flexibility and to
mindfulness practices
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