Chronic Pelvic Pain Evidence Informed Protocol

Abstract

Chronic Pelvic Pain Syndrome (CPPS) is pain in the area below the belly button and between the hips lasting six months or longer. Chronic Pelvic Pain Syndrome can be its own condition or symptom of another disease. CPPS is a complicated situation requiring a combination approach to healing. Treatment is symptomatic abortive therapy to reduce acute exacerbations. There is currently little research on yoga therapy and chronic pelvic pain syndrome. Overall research on chronic pelvic pain syndrome appears to be lacking rigger. Chronic pelvic pain syndrome is a problem for health care providers because it is misunderstood and poorly managed. CPPS has an unclear etiology, complex natural history and poor response to treatment plans of care. Arnold Kegel, in 1950 was the first author to talk about PFM (Pelvic Floor Muscles) and have been recommended for some time. In 1963 Jones suggested that anatomic characteristics could influence the performance of PFM. In 1984 the introduction of biofeedback provided confirmation of the use of Kegel exercise in changing PFM function. In the 1990’s randomized control trials began related to PFM training. CPPS is a public health problem for women throughout the developed world.

Introduction

One in seven women suffer from CPPS outpatient visits in the United States for Chronic Pelvic Pain Syndrome (CPPS) is estimated at $881.5 million per year for women between the ages of eighteen to fifty (Mathias, 1996).  Similar to other chronic pain conditions CPPS may lead to prolonged suffering and a lifetime of therapies while affecting their personal and professional relationships and leading to loss of employment or disability. To optimally manage this condition a variety of health care professionals are needed. A CPPS patient may see a gynecologist, gastroenterologist, urogynecologist, physiatrist, and a physical therapist. It is suggested that the patient and their family be educated on the multifactorial approach to chronic pain. Patients should avoid stressful situations and poor posture. It is suggested that exercise, good sleep hygiene, balanced meals, biofeedback and relaxation techniques may be beneficial to CPPS (Singh, 2015).

The Literature Review

Having a good working relationship between the clinician and patient is a necessity due to the compounding nature of CPPS. A treatment plan should be tailored to the individual with a goal to reduce symptoms and improve the quality of life. While managing the pain using a contemporary approach of both psychological and physical therapy is needed, if a particular cause is found treating this condition as well. The complexity of the pelvis and the anatomical proximity of pelvic visceral means that symptoms frequently overlap traditional medical specialties, leading to diagnostic delay (Vincent, 2008).  Inadequate treatment happens to twenty-five percent of women and often after three to four years they still do not have a diagnosis. During this time these women saw a forty-five percent productivity reduction at work.  CPPS can present anywhere along a spectrum of organ-specific to regional to systematic pain (Vincent, 2008).

CPPS pain symptoms can range from mild to annoying to severe where the patient is missing work, cannot sleep and cannot exercise. Standing for extended periods of time may intensify symptoms; symptoms may be relieved by lying down. Some symptoms that may accompany CPPS are severe and cover a broad range of constant pain, intermittent pain, dull aching pain, sharp pains or cramping, pressure or heaviness deep in the pelvis, pain during intercourse, pain while having a bowel movement or urinating, pain when you sit for extended periods of time.  There is no gold standard diagnostic test for CPPS; it is a diagnosis of exclusion (Sherkhane, 2013). Causes for this condition are complex as there may not be one single cause but many amongst a wide range of conditions including reproductive, GI, urologic and neuromuscular disorders. Diagnosis for CPPS is usually a process of elimination. A detailed past health history, family history, journal of pain and symptoms, pelvic exam, lab tests (infection, blood count cells and UTI), ultrasound, x-rays, CT scans, musculoskeletal (piriformis syndrome, dysfunction of obturator muscle or fascial, herniated disc, dysfunction of psoas or flexion abduction and external rotation)  and MRI’s (Neis, 2009).  What women want out of a CPPS consultation is personal care, to be understood, to be taken seriously, explanation and reassurance (Vincent, 2008).

The pharmacology of CPPS generally starts with pain relievers such as aspirin, ibuprofen, and acetaminophen. It is common to prescribe hormone treatment (birth control) and/or antibiotics (tizanidine) and/or antidepressants (doxepin, desipramine, protriptyline, buspirone).  Other therapies prescribed are physical therapy (stretching, massage, relaxation techniques, TENS-transcutaneous electrical nerve stimulation), Neurostimulation (spinal cord stimulation), trigger point injections, psychotherapy (working on root cause cognitive behavioral therapy), biofeedback, acupuncture, meditation and deep breathing. If surgery is an option the most popular surgeries used are laparoscopy and hysterectomy. Other surgery procedures may be presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation) and uterovaginal ganglion excision (inferior hypogastric plexus excision) (Singh, 2015).  Tizanidine is not a conventional method; the theory is that it may provide improved inhibitory function in the central nervous system. Selective Serotonin Reuptake Inhibitors (SSRI’s) such as Prozac, Paxil and Zoloft are commonly prescribed to CPPS patients (Singh, 2015).

Pelvic floor muscle (PFM) function is a group of muscles and connective tissue that extends as a sling across the base of the pelvis (medical dictionary). It is comprised of two layers, the superficial perineal muscles and the deep pelvic diaphragm providing support for the pelvic organs, the bladder and elements of the spine.  Stiff muscle fibers have a decreased ability to generate power. Overactive pelvic floor muscle (OPFM), experience muscular weakness and early time-to-fatigue. PFM have a higher percentage of slow fibers to maintain its tone and contraction, except during voiding.  Alternative methods, such as Pilates and Yoga may be an effective tool to improve the strength of the body core musculature (Marques, 2010).

Comorbidities for CPPS are depression. The association between abuse, psychological morbidity, pathology, and CPPS are sufficiently consistent and suggest that they may well be causally related (Latthe, 2006).  CPPS is challenging treatment strategies most successfully if they are undertaken in a broader scope of an integrated care model (Engeler, 2013).

 

Pancamaya Model

Yoga therapy can be used as a self-treatment tool for CPPS.

Annamaya Kosha- Muscle guarding is a sign of a tight pelvic floor and is a maladaptive self-protection process that leads to injury and increased pain. Nerve pain leads to muscle atrophy which may cause less blood flow. The diaphragm works in coordination with the pelvic floor. Think of the autonomic nervous system as yin and yang. The sympathetic nervous system is our flight, fight, and freeze pain is overactive here as our run from the bear chemicals is in overdrive.  The parasympathetic nervous system is our rest, and digest and our chill out chemicals are working. Vigorous yoga with lots of sun salutations and lunging is not a good fit for CPPS. A treatment plan using gentle and restorative yoga, while using language on letting go,  and allowing the nervous system to relax is more efficient.

Pranamaya Kosha- Three part breath and letting go breath, works well with this condition. Shallow breathing deprives organs, and muscles of oxygen and is a common trait in those suffering from chronic pain thus the yoga therapist can guide the patient into conscious pranayama. There is a decrease in Apana vayu energy along with chakras one, two and three. Focusing on expelling exhalation and what is not needed, grounding and cleansing to support the need for becoming calm and rooted.

Manomaya Kosha- Starting with tamas which is a dull mind that is hiding awareness, fear interprets experience and hinders self-inquiry and bringing chakras one and two into balance (imbalance, disorder, anxiety, inactive). Rajas will eventually happen as anger, anxiety, frustration, aggression, and boredom seep in as you balance chakra three.  Grounding meditation while working on survival, emotions/suppression, and breaking powerlessness. Managing the emotions can be done through meditation, chanting, mudra, journaling and so on.

Vijinanamaya Kosha- Discussing ahimsa “do no harm” teaching the patient to not push to discomfort because they will gain more by listening to the boundaries their body is telling them. Learning to parent ourselves through listening to the body and mind with kindness. Ishwara Pranidhana is letting go of control and practicing humility so looking at your yoga practice not as what it can do for you but approaching it as a practice in the spirit of an offering. This niyama is a way for us to listen to our minds and to dissolve the endless agitations that may live there.  Swadhyaya letting go of blame and practicing curiosity this can be looked as self-study that uncovers our strengths. It can also be a way to ruthlessly reveal our weakness such as habit patterns and negative tendencies. While this may be uncomfortable work the grace of it is locating the soft spot and not beating ourselves up for what we perceived as a fatal flaw. Learning to welcome and accept our limitations as we do this we get close enough to ourselves to see the roots of our anger, impatience, and self-loathing and instead meet it with compassion for the conditions that molded the behaviors and beliefs in the first place. Aparigraha is letting go of expectation and practicing letting go or flowing with whatever comes our way it is a way for us to practice letting go of some of the physical, emotional and mental baggage that we amass during our journey. We let go it opens up our energy so that something new can come allowing us to grow. It is cleaning out the clutter physically and emotionally, forgiving ourselves and others, observing nature enabling it to teach us to flow along the journey and to learn about our breathtaking it on and off the mat.

Anandamaya Kosha as you focus on security, self-nourishment and self-empowerment then fear and anxiety are released, inner nourishment increases and clarity arises. Sensations of comfort and bliss can stem from the pelvis while radiance unfolds naturally. An inner peace and harmony are obtained.

Yoga has been found to be effective in reducing pain intensity and improving function; however, studies do not mention the sampling methods used (Sutar, 2016).

Evidence Informed Protocol

A yoga therapist can help by addressing a four process treatment plan creating awareness, releasing and relaxing the PFM, engaging PFM, and using the chakras and koshas (Prosko, 2016).  First address security and survival, then self-nourishment and desire, finally self-empowerment and assertiveness. Poses such as knees to chest, twists, pigeon, child’s, supine butterfly, happy baby, third world squat are a few asana to start.  First teach the client about the bones, muscles, and joints of the pelvis. Creates a foundation on which to build further concepts off and gives us a working language for the workshop. The pelvic floor is the antagonist of breathing muscles and helps with breathing coordination.  Two pubic symphysis joints (PSJ,) note this is not a real joint; it is a fibrous cartilage that doesn’t allow for much movement, two sacroiliac articulations (SA)-real joints between the pelvis and sacrum, the fifth joint is between the sacrum and coccyx. Coccyx can move forward and back and which affects the tension in the pelvic floor muscles. Then move into creating flexibility for the pelvic floor. Many pelvises are tight, so first, we will talk about flexibility. A gripped muscle doesn’t allow strength to take hold which is why flexibility is next. Some asana may be the cow-face pose, pigeon pose, cobbler’s pose, supine pigeon, supported bridge. Develop strength to hold the organs in, to create power to build a strong core. Some asana may be Mountain with a block, chair pose, bridge pose, one-legged bridge, warrior 1,2,3, triangle pose, goddess pose, cat/cow, crescent lunge. Putting it all together and creating a visual picture and felt a sense as a way to embrace the relevance of the pelvic floor.

Discussion

Even though research is scarce for CPPS, it is important that every female who presents to a health professional with pain at whatever age be taken seriously. Validating the experience, managing chronic pain, managing musculoskeletal and psychological secondary consequences must be maintained and is best done within a multidisciplinary setting, will reduce the burden of chronic pelvic pain in women. Chronic pelvic pain is a common disabling condition that has been poorly studied. There is uncertainty about the causes and best treatment (Latthe, 2006). Studies designed with long-term follow-up would be useful in establishing yoga-based intervention as a treatment modality for functional pain disorders.  Soothing pitta imbalances and centering vata imbalances is critical while cultivating a sense of comfort and inner nourishment is an effective antidote for issues of codependency and compulsive behaviors.

 References

Engeler DS, et al. The 2013 EAU Guidelines on Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit, a Philosophy, or a Science? 10 Years of Development. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.04.035

Janssen, E. B., Rijkers, A. C., Hoppenbrouwers, K., Meuleman, C., & D’hooghe, T. M. (2013). Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Human Reproduction Update, 19(5), 570-582. doi:10.1093/humupd/dmt016

Latthe, P. (2006). Factors predisposing women to chronic pelvic pain: systematic review. Bmj,332(7544), 749-755. doi:10.1136/bmj.38748.697465.55

Marques, A., Stothers, L., & Macnab, A. (2010). The status of pelvic floor muscle training for women. Canadian Urological Association Journal,4(6), 419-424. doi:10.5489/cuaj.963

Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, healthrelatedquality of life, and economic correlates. Obstet Gynecol. 1996 Mar. 87(3):3217.[Medline].

 

Neis KJ, Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist’s and

an endoscopist’s point of view. Gynecol Endocrinol. 2009 Nov. 25(11):75761.

[Medline].

 

Perineal muscles | definition of perineal muscles by … (n.d.). Retrieved from http://medical-dictionary.thefreedictionary.com/perineal+muscles

Prosko, S. (n.d.). Optimizing Pelvic Floor Health Through Yoga Therapy. Yoga Therapy TodayWinter(2016), 32-48.

Sherkhane, N. R., & Gupta, S. (2013). Ayurvedic Treatment For chronic prostatitis Chronic Pelvic Pain Syndrome: a Randomized Controlled Study. International Journal of Ayurveda and Allied Science,2(3), 52-57. Retrieved March 1, 2017.

Singh, M. K., MD. (2015, January 13). Chronic Pelvic Pain in Women. Retrieved March 9, 2017, from http://emedicine.medscape.com/article/258334-overview#a6

Sutar, R., Yadav, S., & Desai, G. (2016). Yoga intervention and functional pain syndromes: a selective review. International Review of Psychiatry,28(3), 316-322. doi:10.1080/09540261.2016.1191448

Vincent, K. (2009). Chronic pelvic pain in women. Postgraduate Medical Journal,85, 24-29.   doi:10.1136/pgmj.2008.073494

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Embodying the Restorative Practice in the Pancamaya Model

Restorative yoga provides a balance between physical and mental that allows the individual to manage stress and anxiety through the supportive use of props that allow you to hold the pose for longer periods of time with ease.  A restorative yoga sequence typically involves a handful of poses, supported by props and retained for five to twenty minutes. Restorative poses include light twists, seated forward folds and gentle backbends and inversions. A lot of restorative poses based on the teachings of B.K.S. Iyengar. You get the benefits of deep, passive stretching while learning the life skills to reflect and rest. Lives are lived at such a fast pace, a restorative practice allows you to manage your nervous system and move into the parasympathetic nervous system, a slower paced system. As you practice restorative yoga, you develop an expanded awareness of self and introspection. There is a profound oneness on a universal level of consciousness while feeling safe and nurtured.

Introduction

To maintain a sense of center and balance in our lives, we must work with all the layers of the Pancamaya model. At one point in our healing history, we thought we could treat human beings by applying the biomedical model of health thus treating purely biological factors while excluding psychological, environmental and social considerations. Research has shown over the years the interplay of biological, psychological and social considerations, while this is a new way of thinking in western medicine; it is not new in yoga teachings. As the ultimate goal of yoga is to have freedom of sukkah (movement/ease) and freedom from dukkha (suffering/pain), yoga therapy is a safe place to start to explore our physical body, energy body, learning body, the body of belief and our bliss body. Restorative yoga by nature is a receptive practice, and that receptivity can guide you toward a healthy state of being. When you are in passive postures feeling supported by the props you release the grip of muscular and inner tension, become spacious and receptive, and are exploring what happens when you slowly release your habitual holding patterns. Our curiosity grows and we question, what am I left with? Can I accept this new space within my body, mind, and spirit?

Personal Practice of Restorative Yoga

During my therapeutic practice with Margareta Ewald at Mind Body Balance, I experienced four restorative poses which were crocodile, hero, supine Tadasana and mountain brook. She used the yamas with each posture. In crocodile, she used ahimsa (non-violence), hero asteya (non-stealing), supine tadasana Aparigraha (non-coveting), and mountain brook sayta (truthfulness). She matched mantra and color with each pose as well. In Crocodile “I softly surrender” with the color gold. Hero the mantra was “I control my health” with the color green. Supine Tadasana “I can let go of what does not serve my greater good” with the color yellow. For mountain brook “My truth guides me” with the color blue. She mainly focused on equal ratio breath throughout the practice.

 I spent approximately ten to fifteen minutes in each pose. In hero pose, I used two bolsters and a chair. One bolster was under my bottom between my legs, and one bolster was on the chair, and my hands grabbed onto the chair. In supine tadasana, my feet were against the wall, a blanket under my knees, a sandbag on my femur bones and neck roll. In crocodile, I had a blanket folded in fours that started under my last rib and covered my belly with a rolled mat under my ankles. In mountain brook pose I had a bolster under my knees, a folded blanket under my ribs and a neck roll. This sequence appeared to focus on the chakras of three (Manipura), four (Anahata) and five (Vishuddha). Her use of the yamas allowed for me to relate to my world immersed in ethical guides that were faithful to my inner wisdom.

I feel the practice followed the Pancamaya model. There was the physical practice of the poses – annamaya physical body to be nourished. The incorporation of equal ratio breathing allowed for the –pranamaya energy body to be fed by my life force. The use of chakra and color- manomaya, learning body, to focuses my feelings and emotions that I felt. At times I felt sadness, complete surrender, and joy. The use of the mantra-vijnanamaya body of belief allowed me to focus the patterns of mind onto one right design that supported my greater good. The multitude of tools used allowed my expansion of self –anandamaya body of bliss as my sense of self-grew beyond my minds limited boundaries.

 Restorative Plan of Care for Anxiety

Anxiety is a normal reaction to stress and can help us be alert to dangers. Anxiety disorders differ from daily nervousness and involve more fear. The American Psychiatric Association state that roughly twenty-five million Americans suffer from anxiety disorders which often cause feelings of panic, fear, and intrusive thoughts and may result in interrupted sleep difficulty, functioning at work, disturbances in relationships and physical symptoms.  Various things contribute to anxiety disorders such as genetic, environmental, psychological and developmental factors. Stress and trauma play key roles in the development of anxiety disorders and triggering of symptoms. Anxiety disorders general have imbalances of the SRS (stress-response-symptom), ANS (autonomic nervous system), HPA (hypothalamic-pituitary-adrenal axis), overactive SNS (sympathetic nervous system) and underactive PNS (parasympathetic nervous system). These imbalances affect the client’s emotional regulation, perception, cognitive function, social relationships and the following systems- cardiovascular, respiratory, gastrointestinal, neuroendocrine and immunological. Yoga Therapy (YT) bottom-up and top-down mechanisms may ameliorate pathophysiological processes that contribute to anxiety through sympathovagal balance and increase the release of GABA (gamma-aminobutyric acid). (Khalsa, 2016)

Stephen Porges and the Polyvagal Theory shows stress can impair the ability to trust and form close, loving relationships. Yoga practices increase PNS and HRV (heart rate variability) and supporting the social engagement systems. The vagal nerve stimulation enhances the release of oxytocin. Yoga increases trust, bonding, and reconnection with Self. Anxiety entails misappraisals of cognitive malfunctions, impaired integration, failure of higher brain centers to modulate over-reactivity of lower centers and stress response, and misappraisal perceptions of danger far in access of presenting reality. While using bottom-up methods in yoga, it circumvents in intellect and activating interoceptive pathways to both higher and lower centers can resolve anxiety and restore impaired cognitive function. (Khalsa, 2016)

An individual presenting with anxiety may be experiencing shallow rapid breath, heart palpitations, excessive worry, vata dosha imbalance, migraines, intestinal problems, obsessive thinking, dizziness, insomnia, and nausea. The overall treatment plan would be to use chanting (sa, ta, na, ma) belly breathing (using a sandbag in C.R.P. –constructive rest position for weight training diaphragm breathing) or balancing equal ratio breath (viloma) to shift from SNS to PNS (pranamaya kosha). Reframing strategy would help in welcoming anxiety symptoms as messengers and recognize them as changing sensations and perceptions. Unpleasant feelings warrant deeper exploration to a root cause (vijnanamaya kosha). Starting with active asana, pala mudra (core quality of reducing anxiety) (LePage, 2014) and moving into a restorative practice (annamaya kosha). The language that the YT uses would be to keep the mind engaged with gentle mindfulness instructions often and exploring svadhyaya (self-observation) woven into the practice (manomaya kosha) and ending with a twenty-minute side lying Savasana with a Yoga nidra meditation (anandamaya kosha).

The asana portion follows Rolf Sovik protocol for anxiety starting with an active series of movement which entails lateral flexion with the rationale of opening intercostal muscles to assist breathing (restorative revolved head to knee pose, chair, two blankets or basic side lying stretch pose, four stacked blankets). Tree pose to practice balance and build confidence (restorative supine tree, wall, strap, blankets as needed). Wide-leg-forward-fold pose with head on the block to quiet the effects of the brain (restorative seated wide-angle pose, blanket and bolster).  Rolling-like-a-ball for twenty reps to massage the spine and playing with inversion in a fun way. Seated twist pose to work with breathing that is restrictive or tight using it as a practice to remedy anxious feelings (restorative revolved knee squeeze pose, bolster and two blankets). The last active pose would be shoulder stand at the wall for thirty or ninety seconds to build comfort in inversion (also wheel over a physio ball works or stacked bolsters). Moving into supported legs up the wall (wall, bolster, two blankets) to get use to the idea of being upside down and ending in restorative crocodile (three blankets) to witness the breath in a safe manner. “Inversions are a powerful way to visit a place of anxiety free living” – Judith Lasater.  Each restorative pose can be held five to fifteen minutes depending on the goal you wish to reach.  (McCall, 2007)

The overall rationale for this practice is to pick a middle road between vigorous and restorative. Moving right into a therapeutic practice when someone is in a high level of anxiety can increase their agitation, therefore having some moderate movement, in the beginning, allows for settling into calming and grounding practices of breath work and restorative asana. This practice was also breath heavy because disordered breathing plays a significant role in both the production and maintenance of anxiety symptoms.  The poses allow for breath awareness into the abdomen, creating a gentle massaging effect that increases circulation and lengthens the exhalation slowing the breath rate helping to reduce anxiety. Apana vayu the downward moving current of energy was activated as well as gently opening the first and second chakras to build on safety and self-nourishment. With greater tranquility we can witness fearful thoughts, and as the symptoms of anxiety decrease, we experience sensations of wholeness.

 Restorative Plan of Care for Back Pain

Back conditions include structural and functional disorders as well as lumbopelvic spine and thoracic pain. Low back pain (LBP) is the most common and while specific causes such as discogenic pain, spinal stenosis is roughly fifteen percent of all back pain. LBP is categorized by the length of the illness acute LBP is up to eleven weeks of pain, chronic LBP is anything exceeding twelve weeks. Non-specific LBP is better approached with a biopsychosocial approach rather than the traditional biomedical paradigm as it allows for a more appropriate understanding.  Biomedical is a better approach to rule out things such as cancer, infection, compression fracture and abdominal aortic aneurysm. The multifaceted practice of yoga and using the Pancamaya model which parallels the biopsychosocial model may be important in the management of LBP.  LBP often appears to somaticize with life stressors.  Therefore the effects of yoga can be contributed to increased physical activity, enhanced body awareness, and reduced maladaptive movements, correction of postural strain and relief of physical and mental stress. (Khalsa, 2016)

An individual presenting with back pain may present with symptoms of weakness; problems with bladder and bowels; persistent aching or stiffness, sleep disturbance; sharp localize pain; pain is radiating from low back to buttock to back of thigh, calf, and toes; and to an inability to stand straight without muscle spasms. Back pain the impediment in which causes pain is a vata dosha imbalance because vata is responsible for all movements in the body. The overall treatment plan would be the breath of joy, hands on heart/belly while breathing, nadi shodana,  chant (Om Mani Padme Hum – the jewel is the Lotus- represents both the direct experience of peace and the desired to share peace with others).  Breath is part of the stress or pain response which is the easiest to consciously change by doing breathing practices, it interrupts the stress or pain response reducing stress and making you feel better (pranamaya kosha) using a gratitude journal, feeling gratitude in the body as a whole and specific body area (vijnanamaya kosha).  Mudra Anudandi with the core quality of back pain relief (LePage, 2014), asana used will be gentle movement with restorative movement (annamaya kosha). The language that the YT uses would be to keep the mind engaged with gentle mindfulness instructions often and exploring svadhyaya (self-observation) woven into the practice (manomaya kosha) ending with a fifteen-minute meditation such as body scans and loving kindness. (anandamaya kosha).

The asana portion follows Judith Lasater’s protocol for back pain which starts with a gentle movement practice into a restorative practice of yoga.  It starts with cat/cow flow for twenty repetitions, into tail wag for five times each side, quadruped twist for five times each side, locust/flight fundamentals three to ten times with a supine pigeon for seven to ten breaths per side.  Then moving into hanging dog pose (using a door, block and strap) to allow the feeling of letting go that brings relief to those with LBP, this pose puts the long muscles of the back in traction using gravity to relieve the habitual postural effects. Supported half-dog pose (use a table or Pilates Cadillac and stack blankets long ways to desired height) gently stretches the muscles along the spinal column and reduces stiffness. Supported Backbend (bolster and 2 blankets) reflects the way a healthy back moves during daily activities improving flexibility being the antidote to slouching. An elevated twist on the bolster (bolster, neck roll and blanket) stretches the external rotator muscles located deep in the outer hips as well as the latissimus dorsi. This pose does multiple functions, stretches the small muscles of the spine, a little inversion which places the lower back in traction, and the back bend helps to release tension on the intervertebral discs. It improves the lungs and diaphragm function and stimulates the kidneys. Supported child’s pose (bolster and two blankets) provides a counterbalance stretching the lower back, relieving shoulder tension and quieting the mind. Basic relaxation pose (chair, sandbag, neck roll, and blanket) with legs on a chair with a sandbag on the belly relaxes the muscles and organs of the abdomen as well as the muscles of the lower back while refreshing the legs. All restorative poses can be held five to fifteen minutes depending on the need. (Lasater, 1995)

The overall rationale for this plan is to release tension from the back and support optimal posture. This practice is designed to direct breath awareness into the entire back, release tension, and increase circulation to the back muscles and to enhance awareness that increased movement supports the optimal alignment of the spine. It balances prana and apana vayus while opening the first five chakras. Over time the practice facilitates relaxation and sense of relaxation that is helpful for back pain. As the individual develops greater trust in the healing, a connection with true Self-deepens naturally cultivating a sense of wellbeing allowing the body to source positive feelings.

Discussion

Yoga therapy is not a talking practice it is a contemplation practice. Suffering becomes functional for our awakening; our pain becomes our grace. Think of the ocean and a wave as they are one, the wave gets puffed up but then it dissolves as we learn to get out of our way; we are just water and full of love. For when we allow our self the permission to experience any pose from within our inner wisdom it is good enough to erode residue that no longer serves us, this is an effort with ease. Restorative yoga gives us the grace to slow down, to listen to our inner wisdom which is the quietest voice within each of us.

References

Khalsa, S.B.S., Cohen, L., McCall, T. B., & Telles, S. (2016). The principles and practice of yoga in health care. Edinburgh: Handspring Publishing.

 

Lasater, J. (2011). Relax and renew: restful yoga for stressful times. Berkeley, CA: Rodmell Press.

 

McCall, T. B. (2007). Yoga as medicine: the yogic prescription for health & healing. New York, NY: Bantam.

 

Page, J. L., & Page, L. L. (2014). Mudras for Healing and Transformation (2nd ed.). Sebastopol, CA: Integrative Yoga Therapy.

           

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Get in Shape & Thrive: Intention

“Intentions are causes that create effect. Choosing an intention is the fundamental creative act. An intention is the reason or motivation for doing what you do. Every act has an intention….it comes from fear or from love.” Gary Zukar

Let’s face it, meditation is hard to prioritize, it feels embarrassing. What should I meditate on? How often should I meditate? Do I use certain words in my intention? Is it okay to use my intentions during meditation to ask for material things? Should I always use the same meditation and intention?  These many questions often get in the way of our actual action of setting time aside to meditate. Artha is one of the four desires in yoga philosophy (Dharma – duty, ethics, Artha – prosperity, wealth, Kama – pleasure, sensual gratification, and Moksha- pursuit of liberation). We can meditate on any of these areas as long as the intention is to support our soul’s dharma.

Yes, there are some who meditate for hours effortlessly. For me, some days three minutes is difficult and I want to avoid it at all costs and then other days forty-five minutes didn’t seem to be enough and it came effortlessly. Why is it easier to meditate in the storms of our lives? When tragedy such as grief and loss happen in our lives all the time, intentions, words, spring from us and we hope. The books that have helped me during storms in my life are How to Survive the Loss of a Love by Harold H. Bloomfield, MD, Melba Colgrove, PHD, and Peter McWilliams and The Ten Things to Do When Your Life Falls Apart by Daphne Rose Kingma.  For many of us, meditation is a struggle because we focus on ourselves and control over life, rather than a higher power.

Rod Stryker, one of my favorite presenters, of the four desires (check out his book The Four Desires) says, “it pays to pursue the meaning of the word itself purusharthas. Purusha roughly means ‘soul’ – the essential Self that is unchanging, that isn’t born and doesn’t die, but belongs to the universe. Artha means ‘the ability’ or ‘for the purpose of.’ Purusharthas means ‘for the purpose of the soul; and the very concept asks that you take the broadest view of your life.”  Are your days balanced in such a way that you feel supported from your inner work? Our spirit is the nonphysical part of us that is the seat of our emotions and character.

Meditate often, honestly, unselfishly, and confidently. Challenge yourself to meditate often. Two books that help me meditate in the morning and evening is The Daily Om by Madisyn Taylor and First in the Morning by Osho. Meditate until you are clear, inspired, and your heart is on fire with love, kindness, and compassion. Now don’t get crazy and act all goofy with your new found energy and annoy your friends. Just allow your heart and mind to engage with your spirit on an intensely personal level. We do this by meditating daily on love, kindness, compassion, intention, and our soul’s dharma. We need to get fired up, meditate, because it is what magnifies the spirit in our lives.

You can do a burn and release session for setting an intention for 2016, then release control and let go.  Take a moment to sit, grounded feet on the floor in your best posture, find your breath, and then begin. Take a piece of paper and write everything you want to invoke. These are feelings and circumstances that you want more of. On the other side of the paper or a new one write your intentions. Start with the feelings or circumstances that no longer serve you, the things you want to release.

Now say something like:

I no longer need the lessons that these feelings, things, or circumstances would teach me. If I haven’t already, I vow to learn these lessons in a different way that feels better and opens my heart.

Burn the list!

I invite these emotions and circumstances into my life this time to serve my highest and best good. I intend that these things will fuel me to be of better service, to be more present and to keep open my heart.

Burn the list!

Suggested intentions to release might be: Thinking you are not enough, breaking promises, dwelling on the past, worrying about the future, living up to others expectations, comparing yourself to others, etc. Suggested things to invoke might be: fun, financial freedom, intimacy, connection, creativity, etc.

Meditation isn’t an option for those wanting to live with mindfulness.

Questions?

  • What priority do you place on meditation?
  • How do you show this?
  • How can you benefit from writing out your intentions?
  • What are the disadvantages to writing them out?
  • How sincere and honest are you in meditation?
  • How can you avoid doing meaningless meditation or having been nap time?
  • What should we practice and what should we avoid? Make a List!

Intention:

Developing meditation and intention toward our greater good draws people to us!

 

Taking a Fast Challenge:

Fasting is a spiritual discipline that powerfully directs our attention towards a higher power. Consider for the next two weeks replacing breakfast, lunch, or dinner with meditation.  Four ideas or places to start your meditation practice from could be:

  1. Candle gazing for 3 minutes daily.
  2. Transcendental Meditation for 20 minutes daily (repeating an Om).
  3. Doing a guided meditation from your iTunes account.
  4. Following your breath in and out for a predetermined amount of time.

Next Steps:

Meaningful-have this be quality time for you

Educate- yourself on what you should practice and should avoid

Discipline- to be honest, confident often, and to prioritize your practice

Intention-allow the healing process to be what it needs to be for your greater good

Try- keep trying, keep practicing

Appointment- make one to meditate

Train- physical movement is good & makes sitting for prolonged periods of time easier

Each- day ask how we can be part of the greater good

 

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You Tube Is Stupid!

Why should you use a studio to learn your movement and not You Tube?

I love the clients that come in and say “Well, You Tube says….. I should do……..” or, “I have……” or, “I can fix myself by doing…..”

WHAT! Look, STUPID is as STUPID does.

Remember when you were a child and you’d watch a show that had some subject matter that probably wasn’t age appropriate. Your parents would talk with you afterward to answer questions/ concerns and remind you that this was make-believe. Everything you saw on TV wasn’t necessarily real or the best way to guide your choices. You Tube is the same thing.

I’m not saying to boycott You Tube but you have to weigh how you came about the information and should you really be following it. This is kind of why I have not jumped on the You Tube band wagon, because people can be really STUPID. I know that is a harsh judgment, but we do live in a nation where we have to tell people that coffee is hot and to be cautious. When I first see a client, their body is one thing to me, the next day it is something different, the next year… and so on. Furthermore, no two bodies are the same. Each body is its own puzzle to be curious about. For me to make a video and say “This is what you need.” is probably not a true statement. It would be like saying you got sick and if you follow this video and it will fix you every time.

Another common problem with YouTube is alignment. You think you are in alignment and doing it right and in reality, you are not. As humans, we need someone to say “yes” and “no” until we learn what we should be doing, feeling, etc. We’ve gotten so far away from movement as a society that we just don’t have the skills to do it productively and reach our goals without guidance. Let’s be honest here too. We don’t take ourselves to the edge, past our comfort zone; we stay where it is comfortable and easy.

Next time you decide to go to the World Wide Web to diagnose and treat yourself, please consider the source.

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