Yoga

Chapter 8 Yoga





CASE


Harrison is a 27-year-old graduate student with past medical history of chronic LBP for 2 years, who presents with a 3-month complaint of bilateral pain in wrists. He currently is undergoing work-up for CTS. He describes pain in wrists upon waking, which lasts for up to an hour. Pain recurs throughout the day, especially after a long duration of computer work. Pain currently is ranked 7/10 bilaterally. It radiates proximally and distally from the wrists with tingling but no numbness. He received physical therapy for his LBP 2 years ago with only fair results. He wants to know if adding a specific daily exercise program or receiving another course of physical therapy will help to reduce his wrist pain and possibly his back pain.



image Initial Examination


Client Report: He was referred to physical therapy by his physician to manage upper extremity pain and reassessment of LBP. He currently is scheduled for a nerve conduction velocity (NCV) study and an electromyogram (EMG) next week. He had a recent follow-up x-ray and MRI of his lumbosacral spine (LS) concerning his LBP. He is active and exercises on a regular basis. He thought that he would be able to “work out” his pain, but this resulted only in symptoms worsening.


Diagnostic Tests: X-ray LS: grade II L4-L5 anterior spondylolithesis; MRI: L4-L5 anterior herniated nucleus pulposus (HNP) 50%


Client Goals: To decrease pain so that he can better tolerate a regular exercise program and daily activities


Employment: Client is a graduate student with no outside employment.


Recreational Activities: Strength training, skiing, hiking, camping


General Health: Good


Medications: None


Musculoskeletal: ROM: Trunk limited in full extension and flexion, bilateral upper and lower extremities within normal limits (WNL) except for bilateral wrists: -5 degrees of extension. Posture: Client presents with forward head and shoulders. Cervical ROM: Restricted in side-bending and rotation at end-range bilaterally.


Neuromuscular: Force generation: Trunk: 4/5; bilateral extremities 5/5 throughout. Sensation: Decreased at C6-C7 dermatomes, R > L. Tests for CTS: +Tinel’s sign and Phalen tests bilaterally. Neural tension tests: +C5-C7 nerve root involvement


Function: Pain: LBP 4/10 in the seated position; 6/10 after moderate physical activity, including ambulation for >0.5 hour, repetitive forward flexion and extension. CTS pain: 7/10 on the right and 6/10 on the left


Outcome Measurements: SF 36=30 (below the standard norm); Oswestry Low Back Pain Disability Questionnaire (ODI) Score=38%, which indicates moderate disability.1,2 Life Stress Inventory=225 implies about a 50% chance of a major health challenge in the next 2 years.3 The use of these measures guides the therapist in Harrison’s perceived stress and disability as it relates to plans for intervention.





image Incorporating CAM into the Plan of Care


The therapist, familiar with yoga, suggests that the client consider trying yoga therapeutics to manage his overall stress and pain and to resolve symptoms of CTS and LBP. Although stress management techniques were recommended throughout the PT course of treatment, little carryover into daily activities occurred. Relaxation and breathing are major components of yoga, and Harrison agreed to try this as an adjunct to his rehabilitation program. The choice of the yoga practitioner was important in this plan of care because he or she needed to be equipped to address specific needs of various impairments and disabilities presenting in a session. Harrison was referred to a yoga practitioner well known to the physical therapist. The practitioner had personal experiences with LBP and had a keen sense of adaptations necessary to progress the therapeutic process of this client and others in her classes.


The therapist had developed a plan of care that included TENS, manual therapy, soft tissue mobilization, and an exercise regimen that focused on flexibility exercises and strengthening the thoracolumbar region and abdominals. The client also was given instructions for establishment of the best ergonomic setup for his work environment. Although the client’s impairments of ROM, strength, pain, and endurance were improving, the client was still not able to attain long-term pain management. His general stress level could potentiate persistent pain and disability. To evaluate the appropriateness of recommending yoga for Harrison, the therapist needs to become familiar with the effect of yoga on his condition. By evaluating the evidence supporting its use in clients diagnosed with LBP or CTS, the therapist is able to safely recommend yoga as an intervention in addition to his rehabilitation program.




Preliminary Reading: Yoga


This client is not alone in his quest to explore yoga as a potential therapy. Millions of people in the United States, whether by their own curiosity or by the recommendation of their doctors, physical therapists, and others, are exploring yoga as a therapy for a broad spectrum of medical conditions.4 In fact, a recent survey of the use of CAM in American adults demonstrated that of those who used yoga specifically as a CAM therapy, 21% did so because it was recommended by a conventional medical professional, 31% did so because conventional therapies would not help, and 59% thought it would be an interesting therapy to explore.5 For centuries yoga has been practiced as a therapeutic modality in traditional Indian medicine.4 Yoga is now one of the most common mind-body therapies used in Western complementary medicine.6 It uniquely brings about physical and mental benefits and involves inexpensive self-care–based activities, which makes yoga appealing as a cost-effective alternative to conventional treatments.7,8 Yoga therapy is an emerging field and is the first attempt to integrate the traditional yogic practice with Western medicine.9 Before they recommend yoga therapeutically, therapists first must understand the traditional practice of yoga.



Overview of Yoga


Yoga is complex. Its long and rich history extends back 5000 years to ancient India. Therefore to explore the totality of yoga within this chapter is impossible. Additional resources are provided at the end of this chapter in Appendix 1 for further exploration of yoga’s history, philosophy, and practice. More information on yoga can be found in Chapter 7.


Yoga, in the traditional sense, is a spiritual way of life that extends well beyond the complicated poses and breath work. The traditional practice of yoga is actually a rigorous spiritual discipline composed of a vast array of physical and mental exercises, in addition to philosophical, moral, and even nutritional practices, all aimed at self-transformation by union of the mind, body, and spirit. As such, yoga truly embodies a holistic approach to life and health. It takes even the most dedicated a lifetime to master. For the most part, however, since its introduction to the West in the late 1880s, yoga has undergone a metamorphosis into a more physically based “fitness yoga.” Many purists, however, still see this Westernized yoga form as an opportunity for exploring the deeper side of yoga and the spiritual aspects of life.9


Yoga is complex even to define. The word yoga has several translations and comes from the root “yug” (to join), or “yoke” (to bind together). Essentially, yoga describes a method of discipline or means of uniting the body to the mind. The National Center for Complementary and Alternative Medicine (NCCAM) classifies yoga as a mind-body therapy, defining it as “yoga—this combination of breathing exercises, physical postures, and meditation, practiced for over 5000 years, calms the nervous system and balances body, mind, and spirit. It is thought to prevent specific diseases and maladies by keeping the energy meridians open and life energy flowing.”5 Yoga, like other mind-body therapies, is centered on development and/or enhancement of physical, psychological, and spiritual health.10 Yoga’s belief system that strongly claims mind, body, and spirit are interwoven is manifested and realized through the dedicated practice of yoga.9



Yoga Practice


What is commonly referred to as “yoga” in the West is actually Hatha yoga, one of dozens of types of Hindu yoga practiced around the world today. Hatha yoga is the “yoga of activity,” with a higher focus on physical postures, deep breathing exercises, and meditation in contrast to other forms of yoga, which may focus more on ethics, meditation, or diet. Because it is one of the types of yoga one can experience, its tangibility has made it the most popular form of yoga practiced in the West and the most practical therapeutically. All styles of yoga, however, are said to lead down the same path, that being toward spiritual enlightenment through self-transformation.9


The traditional path of Hatha yoga is said to involve eight components, or limbs, to attain a person’s full potential and live a purposeful life.9 These components are a prescription for self-discipline, and they direct attention towards one’s body, mind, and overall health. These eight paths include (1) moral precepts, (2) personal behavior concepts, (3) physical postures (most familiar to Westerners), (4) conscious regulation of the breath, (5) focus of the senses inward, (6) concentration, (7) meditation, and (8) ecstasy. Each path is meant to lead to the next. Although to mention these paths of the traditional Hatha practice is important, the focus for this client should center on the more physical and mental aspects for which Hatha yoga is known and that the client would most likely encounter. Several elements in Hatha yoga exist, which include physical postures (asanas), breathwork (pranayama), withdrawal (pratayahara), concentration (dharana), and meditation (dhyana).


The physical postures, called asanas, are designed to purify, cleanse, and gain mastery over the physical body to allow the body to prepare for meditation or stillness.11 In the yogic view, a strong, flexible, and conditioned body is necessary as a foundation for the higher spiritual pursuits. Although not typically considered an aerobic exercise, these yogic postures are meant to help the client develop strength, flexibility, and endurance in muscles and improve circulation and alignment in spine.9


More than 200 actual asanas exist, each with its own purpose, which creates a system designed to seek out every muscle, joint, and ligament and exercise it.9 Within a pose, certain muscles are meant to be flexed, others stretched, which enables relaxation and improved flexibility. Procedures exist for entering, holding, and emerging from each pose, along with specific sequences of poses. Movements are typically slow and coordinated with controlled breathing so that full inhalation is achieved upon entering the pose. The pose and breath are held briefly and then released simultaneously so that the starting point is reached at full exhalation. Every pose has a counterpose to balance its effects.


Typically every practice uses a variety of poses; most involve the muscles of the back and abdomen (Figure 8-1). Standing poses are designed for centering and alignment (Figure 8-2). Seated poses are designed to be more calming than the standing poses (Figure 8-3). Forward bends, with flexion in the hips, rather than the spine, can be done seated, standing (Figure 8-4), supine, twisting, balancing, or inverted. Balancing postures are designed to develop the body’s coordination and strength (see Figure 8-2). Twisting poses help activate the spine, internal organs, and muscles (Figure 8-5). Backbends are meant to strengthen the extensor muscles, stretch the flexor muscles, and stimulate the entire nervous system (Figure 8-6). Inversion postures are said to strengthen the cardiovascular system and obviously reverse the effects of gravity (see Figure 8-4).








Many various styles of Hatha yoga exist, each approaching the asana practice in a particular way (Table 8-1). Some use faster, flowing asana movements, such as Ashtanga, whereas others, such as Iyengar, use poses held for longer durations with attention to detail. Iyengar is one of the most popular styles in the West and uses props to accommodate special needs of the yoga instructor Viniyoga is another popular form, which allows poses to be customized to the individual; thus it is good for students with physical limitations.


Table 8-1 Different Schools of Hatha Yoga Commonly Practiced in the United States







































































































































































SCHOOL FOCUS DESCRIPTION
Iyengar Detail Technical yoga, an intense focus on the subtleties of each posture; great for beginning students
    Strong focus on precise muscular and skeletal alignment; emphasizes therapeutic properties of the poses
    Poses (especially standing postures) are typically held much longer than in other schools of yoga to focus on alignment
    Use of props (belts, chairs, blocks, and blankets) to accommodate special needs such as injuries or structural imbalances.
Ashtanga/Power Yoga Fitness Athletic; fast paced and non-stop; not recommended for beginning students
    At the core is linking the breath with each movement thoughout the practice
    Power Yoga is a derivative, using a more creative sequences of postures
Jivamukti Fitness Athletic; highly meditative but physically challenging form of yoga
    Combines an Ashtanga background with a variety of ancient and modern spiritual teachings
    Uses chanting, meditation, reading, music, and affirmations
Bikram/Hot Yoga Healing Athletic; practiced in a room heated to 100+ degrees, thus “hot” yoga
    Sauna-like effect helps move the toxins out of your body
Kripalu Healing Therapeutic; gentle and spiritually focused; Great for beginning students
    Incorporates inner focus and meditation within the yoga poses; focus on alignment, breath, and the presence of consciousness
    Holding of the postures to the level of tolerance and beyond
    Deepens concentration and focus of internal thoughts and emotions
Integrative Yoga Therapy Healing Designed specifically for medical and mainstream wellness settings including hospitals and rehabilitation centers
    Gentle postures, guided imagery, and breathing techniques for treating specific health issues
    Emphasizes the healing process in detail by addressing all levels of the patient: physical, emotional, and spiritual
Phoenix Rising Yoga Therapy Healing Combination of classical yoga and elements of contemporary client-centered and mind-body psychology
    Facilitates a power release of physical tensions and emotional blocks
    Assisted yoga postures, guided breathing, and nondirective dialogue
    Focused on experiencing the connection of the physical and emotional self
Viniyoga Healing Therapeutic; repetitious movements in and out of a posture
    Individualistic; poses are synchronized with the breath in sequences determined by the needs of the practitioner
    Highly adaptable, thus good for students with physical injuries or limitations
Svaroopa Healing Consciousness-oriented, emphasizing the development of transcendent inner experience, called svaroopa
    Promotes healing and transformation; teaches different ways of doing familiar poses
    Emphasizes the opening of the spine by beginning at the tailbone and progressing through each spinal area
Ananda Enlightenment Tool for spiritual growth while releasing unwanted tensions
    Uses silent affirmations while holding a pose as a technique for aligning body, energy, and mind
    Series of gentle poses designed to move energy upward to the brain, preparing the body for meditation.
Integral Enlightenment Aimed at helping people integrate yoga’s teachings into their everyday work and relationships
    Incorporates guided relaxation, breathing practices, sound vibration (repetition of mantra or chant), and silent meditation
Kundalini Enlightenment Dynamic; esoteric; energizing; aimed at invoking dormant spiritual energy at the base of the spine
    Incorporates breath-work, movement, postures, chanting, and meditating on mantras.
Sivananda Enlightenment Traditional approach; can become very advanced
    Ridgid class structure of poses, breath-work, mediation, and relaxation.
    Emphasizes 12 basic postures to increase strength and flexibility of the spine
    Focus on proper pose, breathing, relaxation, and diet (vegetarian), and positive thinking and meditation

Generally associated with the asanas is breath control, a practice called “pranayama,” which also can be used as an isolated practice. The pranayamic breath is meant to be deep, rhythmic breathing through the nose during inhalation and exhalation. Pranayama is designed to gain conscious control of one of the most basic and largely unconscious bodily functions and allows realization of the connection between the breath, mind, and emotions.9 In the yogic view, if the breath is calm and controlled, so can be the mind.4


Two other limbs of the yogic practice, pratyahara (withdrawal of the senses) and dharana (concentration), are important skills that increase attention and awareness. Practicing these two paths is said to place a person in “the zone” and helps bring awareness to positioning and posture. These are also important practices that allow people to sense and understand the limitations of their bodies.9 These practices allow someone to draw attention inward, learn to recognize habitual thought patterns, and become aware of the body and its rhythms. The practice of meditation, or dhyana, results in uninterrupted concentration aimed at quieting the mind and body. It commonly is used as a practice apart from the other yogic practices.9

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Mar 11, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Yoga

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