Historical Perspective

The guest editorial of the November 2007 Journal of Orthopaedic and Sports Physical Therapy proclaimed: “Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come.” The editorial concludes with, “… further investigation of the regional-interdependence concept in a systematic fashion may add clarity to the nature of many musculoskeletal problems and guide subsequent decision making in clinical care. Regional interdependence is a model whose time has come.” Although such a model is very helpful in managing complex hand and upper quarter rehabilitation cases, the historical context has been lost. Consider that over 3000 years ago in the Taittiriya-Upanishad of the Indian Vedanta doctrine the sheaths or koshas were described in Yoga extolling the value of understanding that not only is physical regional interdependence important in optimizing health, but so to all the other aspects of the human experience to include social, emotional, psychological, and spiritual influences. The kosha model described bears many similarities to both the regional interdependence model and the biopsychosocial model as used in chronic pain rehabilitation. Historically, it is accurate to say those models actually resemble the kosha model. Hence this chapter explores this ancient model and its history of theory and technologies developed over the millennia as what we know today to be yoga therapy and how Yoga therapy can complement traditional hand and upper quarter rehabilitation.

Presently in the West, Yoga therapy is classified as part of complementary and alternative medicine (CAM), as defined by the National Center for Complementary and Alternative Medicine (NCCAM). CAM is a group of diverse medical and health-care systems, practices, and products that are not presently considered to be part of conventional medicine. Techniques include, but are not limited to, naturopathy, meditation, chiropractics, prayer, guided imagery, acupuncture, energy healing, and therapies that use creative outlets such as art, music, or dance. A recent survey revealed that of those who used yoga specifically for therapeutic purposes, 21% did so because it was recommended by a conventional medical professional, 31% did so because conventional therapies were ineffective, and 59% thought it would be an interesting therapy to explore. Yoga therapy is now classified as one form of movement therapy that has gained increasing popularity over the past decade. For centuries, the virtues of Yoga as a therapeutic modality have been extolled in traditional Indian medicine. More recently, Yoga therapy has gained popularity in Western culture and is now the most common mind–body therapy in Western complementary medicine. Its unique ability to facilitate spiritual, physical, and psychological benefits make Yoga therapy appealing as a cost-effective alternative to conventional interventions. Yoga therapy is an emerging field with a professional association of over 2400 members, 40% of whom have dual training in fields including physical and occupational therapy and speech and language pathology. The organization has grown from 600 members in 2004 to its present size. Such growth demands a further consideration, but before Yoga therapy can be fully adopted and integrated into standard practice, additional evidence is required. The organization has sponsored the first two research symposiums on Yoga therapeutics bringing researchers together from around the world.

Yoga utilizes movement, proprioception, breath modification, and education principles that create a natural correlation to the tools of physical rehabilitation of the upper extremity. Conceptually, Yoga refers to that enormous body of precepts, attitudes, techniques, and spiritual values that have been developed in India for over 5000 years. The word Yoga has several translations and comes from the Sanskrit root yug (to join), or yoke (to bind together). Essentially, Yoga describes a method of discipline or means of discovering the integral nature of the body and mind. For millennia, Yoga has been considered standard practice in Eastern medicine. It has more recently gained general acceptance within Western civilization, primarily as a supplement to conventional interventions.

Despite its long history of experiential inquiry and modifications, only recently have investigators begun to subject Yogic concepts to Western empirical methodologies. The effects of Yoga therapy have been explored in a number of patient populations, including those with asthma, cardiac conditions, arthritis, kyphosis, multiple sclerosis, epilepsy, headaches, depression, diabetes mellitus, pain disorders, and gastrointestinal disorders, as well as in healthy individuals.

Guiding Concepts and Origins

Although Yoga originally developed in the Indian culture with origins from the Hindu, Jain, and Buddhist traditions, it is a philosophical life science with far-reaching practical applications. The practice of Yoga is congruent with all religious traditions and demands no belief in deities or practices that would conflict with an individual’s spiritual tradition. The physical postures and motor performance outcomes that characterize so much of Yoga within Western culture is actually a by-product of what is more accurately described as a technology for the evolution of the mind or consciousness. The essence of Yoga therapy is the experiential bridge it provides to the mind–body science of current pain and motor theories as complex, distributed, self-organizing, and representational phenomenon. This emerging awareness by Western science of the mind–body connection is the rediscovery of what has been the basis of the practice of Yoga for thousands of years. The basic tenet of all branches of Yoga focuses on experiencing the unity of the mind and body, as well as developing spiritual, psychological, and physical health.

A summary of the philosophy of Yoga most familiar in the West was made nearly 2000 years ago in the Yoga Sutras , a text written by the philosopher and physician Patanjali, whom many consider to be the father of modern Yoga. In his treatise, Patanjali included an eightfold path to enlightenment designed to help individuals transform themselves, gain control over their mind and emotions, as well as physical stability and ease ( Table 121-1 ).

Each limb of Patanjali’s model acts as a practical science for the relationships among thoughts, emotions, memories, intentions, and actions. Each limb emphasizes moral and ethical conduct as well as self-discipline. Patanjali’s eight limbs on the road to optimization of human potential include moral precepts (yamas), personal behavior concepts (niyamas), physical postures (asanas), conscious regulation of breathing (pranayama), focusing the senses inward (pratyahara), concentration (dharana), meditation (dhyana), and ecstasy (samadhi) . Traditionally students begin with the yamas and niyamas, and then, only when well grounded in the practice of those, do they embark on the other six limbs in a recursive and inclusive experience of application similar to Covey’s seven habits.

Yoga, as a spiritual science of life has developed technologies for the practitioners to question and verify through their experience of the nature of reality. The technologies extend well beyond the stereotypical complex poses and meditation of the Western branding of Yoga. The practice of Yoga combines rigorous practice discipline with a wide array of physical and mental exercises rooted in moral and ethical principles that address every aspect of modern life from consumer patterns to nutritional and vocational choices. As such, Yoga embodies a holistic approach to life and health as a wellness and prevention practice designed to generate a lifelong series of healthy lifestyle choices. Since its introduction into Western culture in the late 1880s , there has been a significant shift in emphasis from spiritual outcomes forms of practice to more physically based outcomes. This shift toward more physically based practice of Yoga is the result of the adoption of the West’s mechanistic reductionistic worldview. Curiously, as Western science advances it is now coming to reveal how the Yoga model offers a balance of both the Western perspective and the Eastern nonlinear, systems perspective of holism as it relates to human health. Table 121-2 compares the emphases that characterize the Eastern and Western views of Yoga as a consequence of these respective perspectives.

It is not possible to explore the totality of Yoga therapy within this chapter. The reader is referred to additional resources that may be procured to further explore Yoga’s history, philosophy, and practice. Texts written by George Feuerstein, B.K. Iyengar, T. K. V. Desikachar, and Gary Kraftsow are highly recommended and widely praised as the most accessible works on the philosophy and technologies of the therapeutic applications of Yoga.

The Practice of Yoga Therapy

Yoga therapy has become a popular and versatile practice, now being used extensively in Western culture from Yoga studios to major university hospitals. What is commonly referred to as Yoga in the West is usually Hatha Yoga. Hatha Yoga is also known as Yoga of activity, which focuses on physical postures, deep breathing, and meditation. These practices are what is popular in the media and seen in the gym. Yoga therapy, in contrast, includes other forms of Yoga that also focus on ethics, mudras (hand movements/postures), bhavana (guided imagery and meditation), jnana (study), or diet. Hatha Yoga’s popularity is attributed to its physicality familiar to the Western athletic workout, but should be understood not to be the equivalent of Yoga therapy, and Yoga is certainly not just “stretching.” All styles of Yoga, however, are believed to lead to the same path of personal fulfillment through self-transformation, but as outlined later in this chapter in the context of health challenges, the tools of Yoga therapy are far broader and richer than Yoga-like postures adapted as therapeutic exercises.

A desirable feature of Yoga therapy is that each practice can be modified depending on the participant’s abilities and state of health. These characteristics make it an ideal form of practice for all age groups, contributing further to its accessibility and increasing utilization. The only prerequisite for participating in Yoga therapy is that the participant be breathing. Overall, Yoga therapy stresses the importance of the participant’s developing awareness of how what they think, believe, perceive, and have been told influences their physical posture and mobility; their quantity and quality of breathing ; and the level of central nervous system vigilance. All of these ultimately affect their ability to achieve the goals of developing optimal flexibility, health, and vitality.

The Technologies of Yoga Therapy

Asanas (ah·sah·nas), or physical postures, are the most familiar tool of Yoga therapy and have been demonstrated to generate cardiovascular fitness, strength, mood modification, and flexibility. Each posture teaches increased body awareness and optimal biomechanical positioning of the body in space, both in static and dynamic movement. There are hundreds of asanas, each with its unique purpose of enhancing awareness and skill of the effect of thoughts, emotions, memories, and breathing on comfort and stability. The selection of the asana or sequences of asanas represents this holistic Yoga therapy understanding of each asana and is far more complex than just a biomechanical assessment to address stability and inflexibility of the musculoskeletal system. Postures for deep relaxation are introduced from the beginning in order to facilitate perception, reflection, and calming of the central nervous system for improved mind–body awareness. Each asana is designed to elicit awareness of certain musculoskeletal groups while perceiving the release of tension and holding from others for the purpose of promoting relaxation and improving flexibility. In order to maximize the benefit from each asana, they are often slowly repeated with focused attention and then sometimes held for a period of time. Maintenance of selected postures after careful study by the participant of how attention, thoughts, and breathing affects the action into the posture allows for the elongation of muscles safely and naturally with gravity assistance and the further discovery of previously unknown postural patterns of holding and tension. The selection and sequencing of asanas includes not only principles that correlate to therapeutic exercise progression, but also the effects on breathing patterns, thoughts, emotions, and spiritual insight inherent in the asana. It is beyond the scope of this chapter to address that science in its entirety. Typically in Yoga therapy the number and complexity of the asanas selected is much lower than a typical Yoga class. The following are brief descriptions of five yoga postures that are in common therapeutic use. Savasana, or corpse pose ( Fig. 121-1 ). Tadasana, or mountain pose ( Fig. 121-2 ). Dandasana, or staff pose in a chair ( Fig. 121-3 ). Matsyasana-supported, or fish pose ( Fig. 121-4 ). Half-uttanasana, or half-forward bend against a wall ( Fig. 121-5 ).

Savasana. Supine, comfortably supported with additional pillows and towel rolls; legs comfortably apart, hips relaxed; arms slightly away from the trunk, palms turned up as is comfortable; watching breathing happen.

Tadasana. Standing, feet comfortably close together, toes spread wide, and reaching long without clutching; palms facing one another, shoulders down, head held high, and breathing fully.

Dandasana. Seated, same as Figure 121-2 , only hips and knees are bent.

Matsyasana–Supported. Resting on a thoracic spine on a rolled blanket or soft foam roller, arms comfortably away from trunk, palms up; legs either straight or soles with hips abducted and externally rotated; breathing deeply into the lower abdomen.

Half-Uttanasana. Hands supported against a wall or countertop; moving toward a half-forward bend maintaining a neutral spine, engaged feet, and extending back through the hips.

Procedures are followed for entering into, holding, and emerging from each asana, along with a recommended sequence of asanas that have been found to facilitate deeper awareness. Movements are typically slow and coordinated with breathing so that easy and comfortable breathing is achieved throughout the asana. The linking of sensing of the breath and other bodily sensations is prescribed to decrease agitation and distraction of the thinking mind (prefrontal cortex) in order to become aware of the deeper patterns of fear, attraction, and revulsion (limbic system). Every asana has a counterasana to balance its effects and allow multiple perspectives of experience and perception for gaining new insights and novel action. The deliberate careful movements between the polarities of experience are ancient processes of what is now categorized under such terms as “pacing, scaling, graded exposure, and desensitization” for addressing fear avoidance, hyperesthesia, and kinesiophobia (fear of movement). The Yoga therapist maintains communication with the individual throughout the asana to gain deeper understanding of the less physical issues impeding graceful, painless motion. These new understandings influence the selection of future technologies in a continuous feedback process of clinical decision making.

During the course of a particular Yoga therapy session, a variety of asanas might be used. The lore of Yoga suggests that there are ultimately 84,000 asanas. Although an exaggeration, by altering the individual’s relationship with the field of gravity, symmetry of movement, and the base of support, the possibilities constitute a large number. Consider tadasana (mountain): it can be practiced in standing, sitting, supine, prone, side lying, and upside down. If the individual lifts the arms overhead altering the center of gravity, there are six more asanas to choose from. The selection process by the therapist is driven by an understanding similar to traditional therapeutic progression in terms of load and perturbations but also that within those changes emotional, intellectual, and spiritual responses occur as well. The therapist also often adapts the asana and offers support with props such as belts, blocks, and blankets so the individual can approximate a more complex asana. An easy comparison is the way orthotics, assistive devices, and prostheses are employed in traditional rehabilitation.

The selection of postures depends on many variables. Some cursory guidelines include the following generalizations. Supine and prone asanas place the individual in positions of safety and comfort and therefore are frequently employed early on. Standing asanas are the most demanding and translate well to functional ADL. Seated asanas are less demanding than the standing ones and are often introduced first as part of a therapeutic progression of load and demand. The seated position offers opportunities to bridge from the more stable supine and prone asanas to standing asanas. Balance is taught in all asanas, to include supine and prone positions. Yoga therapists teach balance not as physical end-product of the effort to eliminate postural sway of the body, but as a sensation of even awareness and perception of the whole person in the asana. As awareness is directed throughout from the tip of the toes to the crown of the head of not only spatial positioning, but also tension, emotional content, and absence of awareness, together the therapist and individual integrate the entire experience of the asana. The end product creates the more traditional outcome of “balance” that is experienced as an effortless effort. Twists, backbends, and forward bends add to the variability in asana selection, as elements of each can be employed in all gravitational fields. In general, they accentuate awareness of the core (trunk and pelvis) and visceroreceptors, as well as highlighting movement impairments around symmetry of planes of motion. Inversion asanas are stereotypically the headstand, handstand, and arm balancing asana. A wide spectrum of very sensitive inversion is employed and defined by bringing the head below the heart gravitationally to generate introspection, new perspective, and calming relaxation. The utilization of all of these variables around asanas offers further adaptation of traditional positioning and therapeutic exercises and the possibility of 84,000 seems less extreme, especially when complemented with the next limb of Yoga—regulation of the breath—or pranayama.

Pranayama (prah·Nah·yah·ma), or regulated breathing, is another key aspect of Yoga therapy practice and is the fourth limb of Yoga. There are over 100 different combinations of yoga breathing patterns that may be employed, each designed to enhance awareness and experience of this vital bodily function that is tied not only to respiration but also to consciousness and action. Breathing techniques in Yoga therapy are used as energy management tools helping to curb the effects of increased stress, mood imbalance, and pain. These patterns of inhalation and exhalation bridge the connection between breathing, the mind, and emotions. Ekerholt and Bergland’s article on Norwegian psychomotor physical therapy offers the reader an extensive background piece between these ancient practices and their role in modern rehabilitation.

Germane to hand and upper extremity rehabilitation is the interplay of the upper quarter in respiration and the autonomic state of the patient. A thoracic, sympathetic, chest-breathing pattern utilizing accessory respiratory musculature of the cervical spine and thoracic cage makes significant demands on the upper quarter at a rate of over 17,000 breaths per day. The obvious load and postural imbalances on the upper kinetic chain are readily apparent. The Yoga therapist not only trains alternative breathing patterns through pranayama to decrease these loads, but also assists the individual in deeper self-reflection and awareness to discover the source of the threat to the organism that elicits the sympathetic response. This holistic approach to fear empowers the individual to address its cause rather than just “toughing it through” the rehabilitation session or overcoming the biomechanical limitations of the moment. The development of such introspective reflection yields new understanding for the individual and therapist with it new strategies for action (movement with intention). Examples of fundamental breath regulation are described in detail in the case study video resources (online).

Pratyahara (prut yah Hah ruh) (withdrawing of the senses) and dharana (dhah Ruh nah) (concentration) are important skills that increase attention and awareness and are the fifth and sixth limbs of Yoga, respectively. Practicing these two ancient paths helps to enhance awareness during both rehabilitation and activities of daily living (ADL). The intended outcomes are to still the central nervous system from its level of hypervigilance via augmentation of the integration of the limbic system with the prefrontal cortex and their interplay with the sensory and motor homunculi. The observed behaviors are decreased reactivity to stimuli, increased concentration and focus, and creative motor strategies beyond the habituated. These practices allow the individual to sense his own physical limitations with clarity and accuracy of perception and execution, not clouded by habitual thought patterns or unexamined biasing fear patterns. These concepts are being employed by the U.S. Army and Marine Corp to address post-traumatic stress disorder (PTSD) and other symptoms of central nervous system hypervigilance shared with the complex upper quarter rehabilitation patient. These concepts are more volitional and differ from the practice of dhyana, the seventh limb of Yoga, which creates uninterrupted concentration that quiets the mind and body.

Dhyana (Dhyah·nuh), or meditation, is described as a conscious mental process that induces a set of integrated physiologic changes. The practice of meditation results in uninterrupted concentration aimed at quieting the mind and body. Siegel of the UCLA Mindfulness Research Center defines the mind as “A process that regulates the flow of energy and information.” The reader is referred to Siegel’s The Mindful Brain for an extensive summary and compendium of the research documenting the neurophysiology and integration that generates what he defines as intra- and interpersonal “attunement.” The mental focus developed from Yogic practice serves to increase awareness of movement and to enhance the perception of any aberrant movement patterns that may exist. This increased awareness may serve to promote muscle relaxation and encourage the adoption of more beneficial postures and patterns of movement, resulting in the prevention of misalignment, cumulative stress, and pain. Furthermore, the relaxation component of Yoga therapy practice counteracts the negative effects induced by prolonged stress and chronic pain.

Meditation is not the abolition of all thought—a frequent misconception. It is a very active state of awareness of all the processes of the mind to include sensations, images, feelings, and thoughts. As these products of the mind are observed by the practitioner based on the particular practice being employed, the individual either notes the observation and releases it or holds it for deeper reflection and understanding. Put in the modern parlance of rehabilitation, this practice can be considered the quintessential sensorimotor integration practice. Siegel has extensive commentary on the implications such a practice has for both the therapist and the patient in a therapeutic relationship, which he defines as attunement. Specifically he addresses the deleterious effects on the patient’s ability to breathe well and attain mindfulness if the therapist is stressed, distracted, and lacking in personal integration. Consequently by this phenomenon of attunement, in order to optimize the healing environment, the therapist’s state of the mind influences the patient’s ability to integrate the intervention. Fortunately, directing not only meditation, but the other technologies and those that follow, the therapist has a tendency to assume similar introspective, self-reflective qualities that mirror the desired outcomes. The tools of mudra provide a practical and simple experience of the effect of these technologies to affect the therapist as well.

Mudras are an ancient technology of Yoga that include precise ways of holding the hands, fingers, tongue, or body to produce specific effects in the mind and body. The integral perspective of early practitioners allowed them to understand the fingers and the hand to be far more than just a tool of manipulation and acquisition. Through years of observation and practice, the upper quarter was seen to be the delicate interface between the individual and the rest of reality, filled with the subtleties and richness far beyond a robotic tool of manipulation. How we greet, touch, communicate, and support one another with our hands provides for an experiential connection between one another that generates meaning and community. The loss of function in the upper quarter offers a gateway to discovering this subtle reality for the patient, and mudras provide a practical tool for appreciating and a road back to fully interfacing with their world.

The use of mudras requires extended study with a qualified instructor to harness the full depth of the practice. However, with some basic understanding of the principles underlying the practice, the rehabilitation professional can safely and appropriately complement traditional activities. The first principle is to deepen the patient’s awareness to the importance of maximal restoration of function as the previously noted bridge to the rest of their world. Sharing the possibility of sensing the nuance of upper quarter movement with intention can fuel interest and meaning into what can become monotonous, repetitious drills. A good introduction is to ask the individual to sense the differences in meaning and experience behind the simple mudras of everyday life, such as the raised flat hand of greeting, the supinated hand of receiving, and the raised back of the hand held up in anger. Then together the therapist and individual apply and acknowledge components of meaning to the traditional movements, such as when working for supination of the wrist, does it matter if they inhale or exhale? If they envision softening in an expression of receiving versus struggling to uplift and support? If they broaden their forearm and soften the palm in an act of surrender versus twist the forearm in a maximal striving for a position? The reader is invited to try this example for a deeper appreciation of the potential for creativity in directing therapeutic exercise.

A second principle of mudras is to ask the individual to attend to the effect each movement has on the quality and perceived experience of the sense of breathing. When reaching behind one’s back from below does it increase the sense of filling of the breath on that side of the trunk or decrease it? How about when reaching behind from above? When closing the fingers? And when stretching the hand open wide? These inquiries retain attention to task, decrease agitation, and spark curiosity and further inquiry, thereby creating a calming, centered effect. An excellent warm-up or cool-down is what is known as a hasta (hand) mudra series. The individual attends to the depth and location of filling with the breath with the hands apart as a baseline. Then touching all finger tips and thumbs in hasta mudra #12 ( Fig. 121-6 ). Place fingers in this position, and note depth and location of breath sensation and the difference on several breaths. Then touching only the pads of the small finger in hasta mudra #5 ( Fig. 121-7 ), now place fingers in this position and note any changes in depth and location of breath sensation. Then touch ring fingers only in hasta mudra #6 ( Fig. 121-8 ). Place fingers in this position, and note any changes in depth and location of breath sensation. Then touch long fingers only in hasta mudra #8 ( Fig. 121-9 ). Place fingers in this position, and note any changes in depth and location of breath sensation. Then touch index fingers only in hasta mudra #9 ( Fig. 121-10 ). Place fingers in this position, and note any changes in depth and location of breath sensation. Finally touch only the thumbs in hasta mudra #10 ( Fig. 121-11 ). Place fingers in this position, and note any changes in depth and location of breath sensation. Typically the effect noted is that as one moves from small finger toward the thumbs, the breath flows from the lower body and steadily up to the top of the thorax and throat for the thumbs. The reader is invited to again try the series and note your experience.

Hasta mudra #12.

Hasta mudra #5.

Hasta mudra #6.

Hasta mudra #8.

Hasta mudra #9.

Hasta mudra #10.

The final principle of mudra for application is to vary the body position and sense the variation of experience, ease of mobility, and distance and again the experience of the sensation of the breath. Does sitting differ from standing? From lying supine? From sitting in a forward bend at the waist? From lying supine with legs up on a chair? Generally the more extended the spine, the more open the extension components of the upper quarter, and, conversely, flexion of the spine is said to promote flexion components of upper quarter movement. The variances invite creativity in the rehabilitation session and for home exercise routines as well.

The incorporation of mudras generates a natural segue to visual and motor imagery as the perception of these experiences is often most easily described by images and metaphor rather than abstract conceptual language. The final tools of Yoga therapy explored here make extensive use of image, imagination, and visualization to optimize integration and healing.

Bhavana (imagery) and Yoga Nidra (deep rest) are technologies of Yoga therapy that provide for hemispheric integration as well as conscious and subconscious integration of memories, emotions, and conceptual limitations of the individual. Closely related to motor imagery in current rehabilitation, Yoga therapists have long used these tools of mental representation of sensation and movement without any body movement and in conjunction with movement. In all of the technologies reviewed, image, metaphor, and sensation are purposefully used to invite whole-brain participation and discovery. The language of the therapist facilitates creativity in the experience for the individual while vocalization of experience by the individual deepens his embodied experience and communicates potential clinical information for decision making by the therapist. Yoga therapists have used these tools to address issues of fear in the lives of their students. Reading these texts, there are natural extensions to employing such imagery in assisting individuals in motor performance who exhibit fear avoidance and kinesiophobia. Taken in context with current visual and kinesthetic imagery tools, there is potential for complementing factors in designing protocols and discovering additional applications depending on the individual’s clinical presentation, life circumstances, and history. The individual can also be taught how to create her own applications as a part of her home exercise, testing and modifying them based on her experience and bringing this information back to inform the next treatment session.

In conclusion, although these technologies of Yoga therapy may seem to be far removed from traditional rehabilitation, close study yields many commonalities between them. To some degree an integrative approach to upper quarter rehabilitation both revisits the very old and also becomes the new evolution as it brings in the insights of modern imagery and research. Penfield’s homunculus of both the sensory and motor cortexes with the disproportionately large thumb, hand, and face offers new creativity as the complexities and distributed representation of movement of modern rehabilitation intermingles with old world practices from the other side of the globe. How to evaluate and incorporate the practices is the focus of the next section of this chapter.