Research Evidence and the Science of Yoga

There is very limited evidence to date on upper extremity conditions per se and yoga therapy (for a thorough review and discussion see Taylor et al.⁴). There is only one RCT to date on carpal tunnel syndrome (CTS) and yoga, which was performed by Garfinkel et al.⁵ This study compared the effectiveness of Iyengar yoga with the use of orthoses for patients with CTS. The researchers utilized eleven yoga postures that were designed for strengthening, stretching, and balancing each joint in the upper body. After eight weeks, the results revealed that the yoga-based group had greater improvement in hand grip strength as well as symptoms (pain) and signs (Phalen’s test) associated with CTS compared to either the wrist orthotic or no intervention control groups.⁵ In 2008, O’Connor et al. compared the effects of a yoga-based therapy program and CTS bracing and found that yoga was significantly more effective in improving reports of pain, nocturnal waking, and grip strength while reducing positive results from CTS special tests as compared to current bracing techniques.⁶ These studies had small sample sizes and variability in measurement. More randomized clinical trials are needed that seek to compare yoga to other treatment options for CTS.

Garfinkel et al.⁷ also looked at yoga for hand osteoarthritis in a small study and found it may be beneficial for reducing pain and disability. Beyond those studies, we move to scientific discussion of how yoga may influence hand function. Certainly radiculopathy, central nervous system (CNS) lesions, vascular disorders, complex regional pain syndrome (CRPS), and other generalized peripheral neuropathies may all manifest with signs and symptoms of the hand. Further, psychological factors may contribute to increased perception of symptoms, such as pain and stiffness. Yoga has been proposed as a potential intervention, because it is believed that practicing better positioning and joint posture may help to decrease intermittent compression of the median nerve, while the stretching involved during performance of asanas may help to relieve upper extremity entrapment and compression. Such relief of compression may help to improve blood flow thus decreasing any ischemic effects on nerves. Additionally stress and fatigue may cause psychological changes that may influence the manner in which an individual perceives the world around them. An individual who is depressed or extremely stressed may feel pain at a greater intensity than one who is not experiencing such things. The meditation component of yoga practice may help in reducing some of these psychological influences thus serving to regulate pain perception in hand therapy populations.^7–9

Broadening our lens of scientific relationship even further, the function of the upper extremity and hand is regionally dependent on the function and alignment of the spine and thoracic cage, and there is growing evidence of yoga’s efficacy in complementing back pain care.¹⁰ Recent findings have extended our understanding of the complex relationship of postural stability between the thoracic outlet to include the glottis, the diaphragm, and the pelvic floor.^11–17

The details of this biomechanical relationship are illustrated in the accompanying Video 20-1 (see Evolve website) entitled “The 3 Diaphragms Model.” Any alteration in function at one or more of the three levels affects the stability and control of the whole to include the extremities. Try it for yourself now: Sit up straight, both feet on the floor, looking straight ahead. Repeatedly flex your right shoulder fully overhead noting your natural end range. Now adduct and internally rotate your left femur, hold it there as you repeat the right shoulder flexion, noting any change in both quantity and quality of range. Return left femur to neutral, and repeat. Does your pelvic floor affect your upper extremity function? Indeed that proximal control then affects the entire length of the upper extremity to the finger tips. It works in the opposite direction as well. Abduct and externally rotate your left femur to sense natural end range, and then make a fist with your right hand and retest your hip mobility against your baseline. Release the right hand, and retest. These experiential exercises are simple but illustrate an important mechanical relationship or linkage for patients and colleagues.

While the concept of linkage is fascinating, the real “magic” as depicted in Video 20-1 is the elaborate interplay between the structural arrangement, the influence that has on the autonomic nervous system (ANS), and how cognition and emotions are influenced by, feedback to, and drive structural alignment and ANS function. The recursive cycles of these dynamic systems relationships are the bridges to understanding the biopsychosocial connections of hand therapy. Like nested Russian dolls, each layer contains new layers that fit within the other. An example would be the patient with a Colles fracture that is breathing from the upper chest post-fall, complaining of sleep difficulties, generalized anxiety, and abnormal sensitivity to touch. Walking these biopsychosocial bridges, the clinician can discover that the transference of the 700+ breaths per hour signals the ANS to sustain a hypervigilant sympathetic output, which influences limbic system arousal and subsequent patient narrative from the cognitive centers that send feedback down the chain in a positive feedback cycle—creating more ANS hypervigilance, destabilization of affected proximal extremity stability, poor movement performance, that drives a worsening narrative, and so on in a true Rube Goldberg machine fashion. The therapist’s ability to articulate this process for themselves, their patients, and colleagues from any point in the process will generate a flexibility of perspective and intervention options worthy of yoga’s stereotypical Gumby-renown flexibility. As a point of interest, the 3 diaphragm relationship isn’t some new understanding, rather it is what yogis have described as the three bandhas and their relationship to the earlier described kosha model, which is now spelled out in Western medical terminology.

Returning to the example of the patient with a Colles fracture, the ANS responses described earlier, along with the physiological impact of the injury itself, contribute to sluggishness of the lymphatic system. Remember that it takes a high amount of interstitial fluid to occur before edema is actually visible. Do not wait for visible signs. The faster that normalizing interventions are initiated, the fewer the problems associated with lymphatic sluggishness, including fibrotic changes of soft tissues, articular tightness, and poor quality of motion. If not contraindicated, this patient needs lymphatic stimulation with manual edema mobilization (MEM) (see Chapter 3 and the Evolve website), which, like yoga practice, helps interrupt the cycle described earlier. Resting on this evidence to date, we now turn to the other two legs of EBP.

Clinical Mastery

Hand therapists who incorporate yoga therapeutics experience a freedom to explore patients’ real-life issues and to intervene with an expanded repertoire leading to more meaningful solutions. For example, a traditional way to learn about self-care limitations is to use an activity of daily living (ADL) checklist or a standardized outcome measure limited to predetermined items that may be irrelevant to your particular patient. The practice of yoga therapeutics facilitates patient awareness leading to connections that extend beyond an isolated self-care task. A patient who cries when telling you she cannot prepare a meal might go on to explain how important it is to her to be able to do this because this is how she shows her love to her family.

Therapists who practice yoga therapeutics experience a personal enrichment in and from their patient interactions. We must be clear of mind and focused on the patient, present with and caring about the patient. This type of engagement is invigorating and calming at the same time, and patients recognize that something special is happening even if they cannot articulate exactly what it is. This quality of interaction typically elicits a compliment from the patient that they feel comfortable with you and that they feel you are helping them. For these and other reasons, therapists who practice this way are much less likely to experience professional burnout. They are also more likely to be open to trying new ways of treating and experience their careers as a lifelong education about their patients and themselves.

The practice of yoga therapeutics exemplifies and integrates concepts from each chapter in Part 2 of this textbook. Quieting the ANS reduces pain (see Chapter 12). Being present with the patient is a prerequisite for developing rapport (see Chapter 13). Creating acceptance dispels stigmas and eliminates obstacles that interfere with resolution of symptoms (see Chapter 17). Choosing our words thoughtfully promotes patient self-awareness and participation (see Chapter 14). Conveying respect to our patients helps them feel safe to address fears that feed autonomic hypervigilance (see Chapter 11). Promoting awareness of and integrating core musculature maximizes upper extremity health and function (see Chapter 19).

What to Look at in Your Exam from a Yoga Therapy Perspective

A video recording of your session might look the same to you and your patient, but your experience and that of the patient would be very different. The softening of your grip because of your diaphragmatic breath rather than your harder grip from a habitual chest breathing pattern would allow the patient to relax their forearm as you mobilize their carpals, both videos might look the same but have very different internal experiences for both of you. Consider these ways of examining and assessing patients with hand challenges. The following principles will suggest entry points for the reader to begin a seamless integration of yoga into the most conservative or traditional hand therapy rehabilitation practices.

Examination Principles

Postural assessment is the first pillar of a yoga therapy examination and begins from the base(s) of support (BOS) in all standard postures (sitting, standing, gait, supine, and prone) and is considered to be foundational rather than complementary. Before the primary complaint is addressed, imbalances in the BOS are identified first by the individual and then, if not recognized or sensed, illuminated by the therapist both through proprioception and visual feedback. A fundamental principle of yoga is that alignment of structure dictates the flow or communication of prana (the basic life force) or what in present day language would be described as ground reaction forces and Newton’s third law of motion. To initiate movement or treatment without assessing and intervening to bring awareness and balance to the BOS first would be anathema to the yogic understanding of regional interdependence.

Postural holding habits are a related area of assessment where the individual discovers postural holding patterns with open-ended questions, such as “Where do you feel the most tension in your body in this position?,” and “Which leg is tighter and denser feeling than the other?,” and so on. The therapist’s questions empower the individual to develop an internal awareness rather than merely listing the therapist’s observed patterns. The therapist is helping to identify not only postural also but breathing, emotional, and spiritual patterns that reflect a hypervigilance on the part of the individual. These patterns become the touchstone for home care programs.

Postural awareness and accuracy is fundamental to a yoga therapy assessment. The individual learns the ability to accurately describe observed asymmetries in their various postures without first looking or merely repeating what they have been told but by what they can sense in the moment. This includes regional areas, such as which foot is turned in or out, higher shoulder, shorter rib cage, greater seat pressure right or left, which shoulder is higher off the table, which palm faces more backward, and so on. This active participation by the individual during assessment generates an introspective attitude as they sense, then confirm visually, and then re-sense if they were initially inaccurate to begin their embodied therapy. During this process, the therapist may introduce topics, such as neuroplasticity as their awareness corrects on the spot, homuncular smudging¹⁸ and its importance in motor planning, and the importance of restoring accurate interface between the sensing mind and structural body.

Breath assessment forms the second pillar of a yoga therapy examination. Inclusive of all the Western parameters of rate, volume, and quality, the therapist studies closely the regional movements associated with the act of respiration. The yoga therapist may ask him/herself or the patient, “Is there movement in the abdomen? How much and in which directions?” There are similar questions for the upper quarter, “Is there lateral movement of the rib cage that generates upper extremity movement? The sternum, scapula, head, or clavicles? Tone of the tongue, eyes, facial musculature? A thoracic or diaphragmatic recruitment?” As before, rather than list these observations, the therapist queries the individual to first sense and assess. This continued pattern of recursive observation, sensing, and education weaves throughout the assessments interlacing with the other principles. During this time the therapist can introduce the importance of respiration patterns around both the state of hypervigilance of their CNS and how with over 17,000 repetitions of these movements a day, failure to provide an efficient and stable BOS around breathing will make all other attempts to alter function much more difficult or impossible.

Self-assessment of the organs of sensing is a critical assessment. Yoga Sutra 1:2 defines yoga as the “stabilization of the mind.” A preponderance of focus on the thoughts (one of the senses in yogic theory) generates a lack of awareness of the other sensing fields or an “instability” in function of the mind. Therefore, in yoga therapy individuals are made aware of these fields to initiate moving the mind off the fixation to thinking. If the therapist notes areas of tension or constriction around any of the organs of sensing, further questions are asked or expanded. Again the process of assessment moves activation from primarily the prefrontal cortex and limbic systems to sensory centers of interception and visceroception, generating ease and CNS acquiescence during the evaluation to facilitate optimal motor learning in the “intervention” phase.

These highlighted principles of assessment represent only a small percentage of the available tools of assessment for the yoga therapist. Many of those include observation of movement patterns, strength, and flexibility, which are redundant to traditional rehabilitation assessments. Others require extensive training and study beyond the scope of this chapter. These examples illustrate the manner in which adopting an integral approach to rehabilitation quickly blurs the boundaries of evaluation, assessment, and interventions as well as the roles where the individual becomes a partner in assessment. The therapist also takes on the role of learner in addition to the role of expert. The next section suggests how these assessments generate interventions both in the clinic and at home as a treatment plan that develops through a truly collaborative patient-centered process.

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