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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Case Study Fibromyalgia

Case study for a forty-four-year-old male named Kevin diagnosed with Fibromyalgia (FM). The case study is to inform Kevin how yoga therapy can support him with his health concerns as well as persuade him to challenge some of his belief systems and lifestyle patterns. The purpose of this paper is to communicate how the Pancamaya Model can assist healing at multiple layers of his being and to outline clinical decision making and the rationale of the proposed treatment plan. The plan will also make suggestions of attitudes of behaviors the client may want to consider changing by growing their knowledge on specific topics. An attempt will be made to evaluate client outcome for subsequent sessions as well as a method of evaluation to measure these results. A sample summary of the proposed plan of care for the client’s primary care physician (PCP) is provided. The goal of the paper is to inform the reader concerning FM, to evaluate the written intake form and to persuade toward Yoga Therapy (YT) as a treatment plan. Given the written intake provided about Kevin, I conclude as a complement to his current care plan that Ayurveda and Pancamaya Model tools will change Kevin’s life and lead him on a healing journey.

Introduction

Can you imagine having a disease that causes widespread pain throughout your body, all conventional tests come back normal, and yet your entire life is being affected by this pain? Fibromyalgia (FM) is a disease that knows no gender, culture or age and affects over 10 million Americans a year, with a higher occurrence in women, according to the National Fibromyalgia Association (NFA). This paper will take you through a snapshot of Kevin’s life. Kevin was a security officer at a high-security government facility with “negative air flow” and high mental stress, frustration and anger which he found difficult to manage. He was a volunteer firefighter. He enjoyed socializing and participating in his community. It is estimated by NFA that FM affects 6% of the world population.  The individual patient on average spends $1,000 out of pocket per month above their health care program, while it costs the United States health care system upwards of $14 billion a year and an overall national productivity loss of two percent. What do you do when you are so ill it is affecting every area of your life? You appear healthy on the outside and you may be told you are making it all up. “Controlling the breath is the precursor to controlling everything about your life- the physical body, the emotions and the spirit.” – Sam Dworkis

While we are just beginning to untangle FM and its truths, one thing seems to be clear, it affects the central nervous system, and its symptoms can come on slow or quickly. FM on PubMed shows over nine thousand research studies have been done to date. Some of them are showing there is a difference in physiological abnormalities such as increased levels of Substance P in the spinal cord, decreased levels of blood flow to the thalamus, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function. Given the written intake provided about Kevin, I conclude as a complement to his current care plan that Ayurveda and Pancamaya Model tools will change Kevin’s life and lead him on a healing journey

As a practicing mind-body practitioner for a decade and in school studying to receive my Masters of Science in Yoga Therapy, I have experienced first-hand the struggles of patients with FM and how mind-body modalities of movement including yoga therapy can enhance FM patients’ quality of life. This paper will first discuss a literature review concerning FM. Second, we will examine the Pancamaya model. Third, we will describe clinical decision making, treatment plan, client education and outcome evaluations. Finally, we will provide a summary of professional communication for Primary Care Physician (PCP).

Literature Review

YT can be applied to neurological and immune disorders such as pain and FM. In this literature review I will show that YT may have a role in the treatment of pain and FM by improving physical and psychological aspects as well as a quality of life. The Fibromyalgia Impact Questionnaire (FIQ) appears to be the gold standard for measuring outcomes during FM research. FIQ measures seven factors related to FM: pain, fatigue, anxiety, depression, morning stiffness, awakening unrefreshed and disability.

 Physiopathology may include the central nervous system (CNS) dysfunction related to pain modulation as well as neuroendocrine dysfunction and dysautonomia meaning a disorder of autonomic nervous system (ANS). (Bir, 2016) Researchers seem to agree thus far that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation.

FM is characterized as having a heightened sensitivity to sensory input. It has a complexity of symptoms such as widespread musculoskeletal pain, stiffness, fatigue, disturbed sleep, dyscognition, affective distress and reduced quality of life. (Bir, 2016) At this time there is no diagnostic lab test for FM, but there have been elevated levels of a pain mediator called Substance P found in spinal fluid in FM patients, indicating there is a problem in the processing of pain sensations in the spinal cord and brain which greatly amplifies pain. Their pain is real and can be debilitating even though the sensation is out of proportion to the actual damage or trauma. (McCall, 2007)

The majority of FM patients have four or more co-morbid pain or central sensitivity syndromes (CSS). Irritable bowel/bladder, headaches, pelvic pain, regional musculoskeletal pain syndrome, restless leg syndrome, and chronic fatigue suggest a shared pain processing. (Mist, 2013) FM and its common co-morbid diseases seem to have a central sensitization link. In a randomized, double-blind control study, pramipexole (dopamine agonist), a D3 agonist, has been shown to be effective in FM. Several studies have shown that the biology of depression is different in FM. Dexamethasone test shows no suppression in major depression compared with mostly normal suppression found in FM. The HPA axis is hyperactive with hypercortisolemia in major depression as opposed to relative hypocortisolemia in FM. The depression observed in CSS patients, including alpha-delta sleep has different characteristics. (Yunus, 2007)

Interventions with little side effects such as physical and behavior approaches may be valuable contributors for FM treatment. (Bir, 2016) An eight-week yoga program which included gentle poses, meditation, breathing exercises, coping methods and group discussions with a three-month follow-up showed significant reduction of symptoms of FM. Symptoms of FM that decreased were: pain, fatigue, stiffness, sleep problems, depression, memory, anxiety, tenderness, balance, vigor, and strength. Psychological improvements in coping with FM pain also improved by utilization of problem solving, acceptance, relaxation and activity engagement instead of using maladaptive strategies. (Bir, 2016). Female FM patients underwent an eight-week course in mindfulness-based-stress-reduction (MBSR) and found a modest reduction in anxiety symptoms but no decreased rates for pain or health-related quality of life indicators. However, when they took individuals and did an eight-week trial that included yoga, meditation and education there was a sizeable reduction in pain. These two eight-week programs suggest that a strategy of combining MBSR, yoga, and meditation may be more efficient than any of these techniques done singularly. (Bradshaw, 2012) A twenty-eight percent reduction in FIQ scores was noted after a two times per week eight week Hatha yoga research session. They included a blend of yoga styles including Hatha vinyasa, kundalini, and Iyengar. (Rudrud, 2012) The data seems to be consistent with earlier reports on ‘mindful’ meditation therapies reducing sleep disturbances, fatigue, and depression and improving the quality of life. Sub-analyses have found that only yoga also relieves pain. (Mist, 2013)

FM poses a financial burden on our society both in the use of health care costs and the result of an inability to work and lost income that FM patients face. (Rudrud, 2012)  Titrating practice to the patients’ energy level is critical and requires an understanding of relevant pathophysiology since FM is likely due in part to altered pain processing in the CNS and peripheral nervous system. Additional factors include genetic predispositions, autonomic dysfunction, and emotional, physical or environmental stressors. (Mist, 2013) FM, to our knowledge at this time, does not progress, cause death or do damage to joints, bones, internal organs and so on. (McCall, 2007)

Pancamaya Model

The following will be a snapshot of Kevin’s intake form using the Pancamaya model which will describe the full depth of how yoga therapy can impact his healing process.

Annamaya Kosha/ Physical Body:  Kevin explains his general health as “in pain and surviving.” He is forty-four years old. His physical body feels widespread pain. He has strong areas of pain in his feet, hands, elbows, and shoulders. He indicates symptoms such as heart palpitations, lower abdomen cramping, rashes, fatigue and so on. His current medical conditions include FM (2013) with co-morbid conditions of obesity, sleep apnea, insomnia, depressive symptoms, high blood pressure, glaucoma, gastrointestinal dysfunctions, borderline personality disorder and transforaminal lumbar interbody fusion and posterior instrumentation of L5-S1. He has debilitation for multiple days after engaging in physical activities such as mowing the lawn. He gets to bed at eight p.m. and wakes at five a.m. He does not rise rested, and it takes several hours to get moving. He relies on his furniture during this time. His dietary intake has been irregular, high caffeine, dairy, carbohydrates and nicotine (new to a cessation program) until recently. For work, he walks ten miles a day with heavy boots and carrying heavy cages on his shoulders. He currently takes Colace, Mirilax, Lumigan, Lisinopril, Bystolic, Nortriptyline and Piroxicam. (May want to ask your Dr. about SAM-e S-adenosyl-l-methionine and 5-HTP 5-hydroxytrypotophan as it may help improve tender points) He sees the following doctors: Rheumatologist, Ophthalmologist, PCP, Neurologist, Dentist and at times Psychotherapist. (Possible additional referrals may be: acupuncturist, massage therapist- not deep tissue, marma therapist and an osteopath) As a yoga therapist, I would be interested in observing the following in Kevin:

  • Muscle tension locations,
  • Guarding behaviors,
  • Posture,
  • Ease of casual movements, and
  • Testing limitations in ROM.
  • Also, what planes of motions cause him more or less discomfort?

I am curious to explore the following questions with Kevin to develop more clarity:

  • How long can you sit/stand before you want to sit/stand?
  • How is this affecting your life?
  • Is it getting better/worse/same?
  • Describe a twenty-four hour day in your life.
  • What do you do during your free time?
  • What health care practitioners/therapies have helped you the most? What worked? What did not?
  • Was it pedicle screws or cages?

Right now Kevin has a separation from his physical body and lacks awareness of his Ayurvedic constitution. The goal will be to build body awareness through asana, a standing practice on high energy days and a restorative practice on low energy days. Each practice should be done at 50%-60% of that day’s energy level-less is more, also look at developing an appropriate diet and lifestyle routine for him. Warm sesame oil self-massage before bathing and at bedtime, soothes vata and nourishes skin, joints and nervous system. A fifteen-minute oil massage then taking an Epson salts bath is preferred.

Pranamaya Kosha/ Energy Body: Kevin is having sleep apnea with breath cessation of over one hundred seventy-five times per night and wears a CPAP machine at night. Kevin is sleeping on average nine hours a day. He has significant fluctuations in appetite/diet with associated weight gain/loss. Kevin has gastrointestinal dysfunction with bleed fissures from the colon. His energy levels have been extremely low. Kevin left a high-stress job and his current job has significant physical demands and he must wear a ventilator the entire day. Kevin experiences energetic challenges. He has heart palpitations, anger and anxiety. As a yoga therapist, I would be interested in observing the following in Kevin:

  • Breathing pattern during discussions,
  • Breathing pattern while we did some movement,
  • Where does he breathe the best?
  • What is his self-report of his breath awareness and description?
  • Does he have the ability to calm body tension by calming breath?
  • Does he report that he feels his ability to calm the body with breath?

I would be interested in asking him the following questions:

  • How is your overall digestion?
  • What do you do to manage your stress?
  • How often do you suffer from insomnia and how long does it last? How is your immune system?

Kevin is showing signs of energy blocks especially in the lower chakras and lack of breath awareness. The goal will be to build breath awareness and to reconnect him with nature and other sources of prana. Apana vayu will help to ground the lower chakras and to help with nourishing the eliminatory systems, prana vayu to nourish the immune system and udana vayu to nourish the nervous and endocrine systems.

Manomaya Kosha/ Emotional Body: Kevin experiences headaches and has an informal diagnosis of depression and possible borderline personality disorder. He has very few memories before age seventeen. He feels let down by his health care team and describes his experiences as “shuffle him through too quickly.” His previous job had high mental stress, frustration and anger that he found difficult to manage. He is open to returning to psychotherapy in the future. He experiences mental and emotional challenges and has mental/verbal disturbances. He has experienced significant life events such as the death of sister (2006), recovery of a dismembered child’s body as a firefighter, loss of a job as a firefighter and social community due to his health. He lives near his parents but prefers solitude and therefore does not socialize much. I would be interested in observing the following:

  • Speed of speech
  • His ability to understand what is being taught and is he able to pick it up quickly or slowly
  • Do I see tamasic, rajasic or sattva qualities

Additional questions that I have are:

  • How is your short and long term memory?
  • How do you continue educating /feeding/exercising your mind as you age?
  • How is your mood? Positive/negative/ moody?
  • What does your pain mean to you? Why do you think your pain persists? How much of your life is impaired by pain?
  • How much better do you believe you can feel?
  • How would your life be different if you did not have widespread pain?
  • Is there anything you have discovered about yourself from having widespread pain?
  • Point to where it hurts most? What have you done for it? Does it radiate down the extremity? Numbness, tingling, weakness, dizziness, nausea, altered vision/hearing?
  • Can you tell me about the non-pain sensations you can feel in your body? In areas of pain, tension, or discomfort?

Kevin shows signs of awareness with his thought patterns and emotional reactions. Using Yoga nidra with eyes open, introspective asana, R.A.I.N. meditation and five-minute sprint or gratitude journaling, and introduction to Rosenberg style of nonviolent communication process may help him explore healthy emotional expression.

Vijnyanamaya Kosha/Wisdom Body: He has practiced paganism mostly on his own rather than in a community setting. He prefers solitude. I would like to observe his personality, values, ability to be self-reflective and how he interacts with the world around him. I would like to engage in conversations regarding these questions:

  • What motivates you to live a full life? What do you do every day to feed that interest or passion?
  • How do you view your life experiences? Glass half full or empty? Can you shift that perspective?
  • What old habits are you carrying around that are affecting your ability to be happy with your life?
  • How do you view your communication skills?
  • How open-minded are you?
  • Are you easy going or a perfectionist? Are you demanding of self and others?
  • Do you struggle with boundaries of speaking the truth in a way that can be received?

Kevin is struggling to see the big picture and to flow through the roller coaster of life with its painful ups and downs. The goal will be to teach Kevin to be the witness, to learn how to focus and stabilize the mind and access discriminating intuition which informs us, as he is whole and complete. Meditation, as part of sadhana (practice), quiets the mind (manomaya kosha) and frees us from misperceptions (vijnyanamaya kosha). Journaling this process is a tool for healing on the manomaya kosha and vijnyanamaya kosha by pacifying the mind and revealing wisdom.

Anandamaya Kosha/Bliss Body: Kevin can be prone to frustration, anger, anxiety and depression. His spiritual connection is strong and practices paganism.  His relationships are lacking due to his poor physical health. I would want to observe his level of joy, depressed, ability to be present, scattered, disassociated or connected. Questions that I would have for Kevin would be:

  • What brings you joy? What takes you away from joy?
  • Do you have personal relationships in your life? Do they connect you to your inner joy?
  • How does paganism connect to your inner joy?
  • Do you have a teacher/mentor/guide? What form does that take for you – a teacher, counselor, friend or parent?

Kevin appears to have a strong spiritual connection. I believe getting him to integrate the natural self into everyday living is the challenge. The goal may be to get him to read some spiritual books that align with his belief system and how what he reads aligns with the nature of the true self which is all aspects of life. Yoga Nidra can be used to relax the mind and the body, accessing stillness, peace and bliss as a reflection of our true self. Yoga nidra is a healing technique for all four lower koshas and a way to experience the bliss of the anandamaya kosha. Using meditation, as a method, allows the joy and bliss of anandamaya kosha to arise.

The primary dosha which is present in FM is Vata disease. Ayurveda views FM as having two leading causes. First, there is a disturbance in the nervous system function called vata and the second is an accumulation of toxins and blockages called ama through the physiology. Once these imbalances reach critical levels, the nervous system becomes less stable and aggravating impurities accumulating in the body is the breeding ground for fibromyalgia to be created. Indicating that there is a lack of trust in the universe and at a young age he was imprinted with thoughts of “I am not enough,” safety and security issues.  The kidney stones that he removed in 2014 indicate he is struggling with fear. (Lad, 2008) Vata imbalance expressed emotions that Kevin presents with are fear, anxiety, loneliness, emotional instability, and mood swings. He also shows signs of a Pitta imbalance with feelings of frustration and anger. Often Vata imbalances have ignored body signals or pushed through them. The metabolic fire is burnt out and as a YT we will want to get it moving again.

A difficult and insidious cycle that afflicts FM patients is the sedentary life because exercise is painful. The body feels like cement, the lack of exercise results in weight gain and fuels depression, which then makes it hard to overcome the lethargy of FM. The patient feels heavy, darkness around the eyes and has dullness to the skin. It is important to share with the client that at some point during their movement practice they will turn a corner. As you move your body, the “fuzz” (Fascia) will break up. The importance of movement and stretching is to maintain the sliding properties of the tissues in the body. Fascia seems to be tactilely tighter in pain points, learning to use your breath and stretch can help loosen fascia to make movement easier and more pain-free. Suggesting that the patient develops a movement routine that meets 50%-60% of their energy capacity that day, oil massage before or after their bath/shower, eating warm vegetables and working to learn to manage their stress response can help FM patients deal with a disease that is poorly understood medically and publicly.

Clinical Decision Making, Treatment Plan, Education and Evaluation

Titrating a practice that will match the patient’s energy level that day is important, a one size fits all program does not work because it must be able to flex and flow depending on energy levels. The more the patient practices with consistency, the more they will develop discernment of monitoring their body’s response and make better choices.   There are several contraindications to be aware of with Kevin with FM and the co-morbid diseases he is experiencing.

Contradiction Related Disease
Hot humid rooms Gastrointestinal Dysfunction, Insomnia
Transitioning to quickly FM, HBP, Depression
Full Inversions/ Strong Backbends Obesity, HBP, Glaucoma / Anxiety, Insomnia, HBP,
Strong breathing techniques/ left nostril breathing/ right nostril breathing Anxiety, HBP/ Depression/Anxiety
Strong Twists Gastrointestinal dysfunction (if struggling with diarrhea)
Vigorous repeated flow FM, Insomnia, HBP, Gastrointestinal dysfunction
Undo weight on particular joints (one-limb balances) Obesity
Careful with praise & corrections, avoid practicing near mirrors, eyes open and use grounding meditations Personality Disorder, Depression

Yoga therapy can help by teaching FM patients how to manage their stress response and learning breath techniques which will calm an agitated, nervous system and generate an inner sense of peace. Yoga Nidra and deep relaxation can help them to improve their sleep. Starting a meditation practice can help FM patients selectively focus their awareness and modulate the pain sensations down to a more manageable level. Consistent asana can improve posture and create better alignment of bones, and muscles. Introspective asana can help FM patients express what they are feeling as a huge emotional backlog may be lodged in the tissue causing pain. Sangha “community” therefore encourages patients to join an FM support group. Patients feel alone and misunderstood. A group can help them to share health care professionals, tips and facilitate connection with others.  “Let’s go into where in your body you feel that despair and that sadness, and let’s breathe into that, and release as much of it as we can.” Ana Forest

Kevin’s goal concerning YT is to establish a regular self-care routine to support a healthy life balance, ultimately decrease pain and improve physical functionality and overall quality of life.  Kevin’s home care plan will focus on establishing self-care mindfulness routines such as: creating good sleep hygiene routines, Yoga nidra before bedtime, walking meditation that he can use on his ten-mile walk, eating meditation, nature meditation, learning how to make driving, showering, tooth brushing and shaving a meditative routine as well as starting a journal practice. Eventually, we will build into developing a high energy day movement practice and a low energy day movement practice. We will start on the low energy practice first with a goal to use this as home practice. It is important to understand that FM patients only wake up with a certain quantity of spoonful’s of energy each day and they need to be able to have choices to modify for their needs that day. Other meditations that we may grow into are loving-kindness, separating two arrows and mudra meditations. An example of a good energy day practice may be: (vata reducing practice) mountain, wall push, chair, warrior 1, seated chair twist, low lunge, child’s pose, legs up wall, lotus, staff, one leg seated forward fold, seva pose, Savasana with a natural relaxed breath as they relax into stillness (3 blankets under knees, 1 blanket rolled for ankle, eye open, wrap a blanket around top of head, ears, neck and neck roll). An example of a low energy day practice may be: supported half dog an a table (1 or more folded blankets), supported relaxation pose (5 blankets, block, 2 pillows) towards the end adding some gentle arm movements, Seated Forward Fold leaning on a chair, Supine twist (1+ blankets), heal slides, cobra, and standing flowing twist, spinal movements at a table or counter. The goal for the first session is to go over the intake and create some additional clarity through conversation, set boundaries for our working relationship, to agree upon mutual goals between YT and client, to do a body scan and breath awareness techniques (an audio recording for client will be made and emailed to them).

It is important to teach Kevin that pain can be reduced, managed or eliminated if we move in a range-of-motion (ROM) that does not cause increased pain. If he does move into increased pain, the nervous system sees exercise as a stimulus and responds. If Kevin moves within his respected ROM his body will shift. Small steps make for significant change.  He may surprise himself. Kevin should try to move in as pure of a movement as he can and reduce compensation of which he may be aware. Those that move in their ROM improve faster than those who do not. Often the way the body unwinds and unravels tension and holding patterns is not the way we think it will go. A journaling suggestion for Kevin maybe to answer the following questions:

  • What did I do yesterday that left me feeling overdone today?
  • Do I have less pain than usual the day after YT session/ practice?
  • Am I relaxed and energetic?
  • If I practice YT sessions regularly does my mood improve? How about my sleep?

Realizing it may take longer to notice benefits than for the average person but in time he will continue to see the benefit of practicing. Journaling if he has less pain than usual the day after practice, recognizing if he is relaxed and energetic, as well as mood and sleep improvement will help track the progress that is being made for the mind. Also, using the FIQ and having the patient rate on a scale of 1 to 10 (1 = passive nothing going on and 10 = vigorous and painful) for a workout intensity level and asking that they workout at nothing above a 3-5 will help them learn to do subtle work, effort with ease, allowing for a steady practice of growth with less setbacks or injury.

See Appendix A for Home Plan of Care until the next YT

See Appendix B for PCP letter summarizing YT assessment with proposed plan of care (I would also enclose a YT FM brochure that had the latest research)

Conclusions and Future Study

Teaching FM patients to fully participate in CAM programs such as YT may produce long-term benefits and help erode self-defeating beliefs by taking control of their self-care. (Bir, 2016) A greater number of randomized control trials (RCT) are needed and current research supports YT as CAM for FM. Participants who completed weekly journals suggested increasing it to more than once a week because it did not capture the richness and variability of their experience. (Rudrud, 2012) Future research determining the role that a charismatic or caring YT plays rather than the intervention itself along with standardization of protocols, scripting mindfulness interventions, posture sequences and a range of modifications is needed. (Mist, 2013) CSS paradigm seems an important new concept with considerable significance that deserves further exploration. (Yunus, 2007) This growing body of research is proving that FM is not a made up disease and one that needs to be taken seriously.  Allopathic, Ayurveda, and Pancamaya model tools can lead to an incredible healing journey.

References

 

Bir, S. K., Cohen, L., McCall, T. B., & Telles, S. (2016). The principles and practice of yoga in

health care. Pencaitland, UK: Handspring Publishing Limited.

Bradshaw, D. H., PhD., Donaldson, G. W., PhD., & Okifuji, A., PhD. (n.d.). Pain Uncertainty in

Patients with Fibromyalgia, Yoga Practitioners, and Healthy Volunteers. International Journal of Yoga Therapy, 22, 2012th ser., 37-45.

Frawley, D., & Kozak, S. S. (2001). Yoga for your type: An Ayurvedic approach to your Asana

practice. Twin Lakes, WI: Lotus.

Lad, V., & Durve, A. (2008). Marma points of Ayurveda: The energy pathways for healing body,

mind, and consciousness with a comparison to traditional Chinese medicine. Albuquerque, NM: Ayurvedic Press.

Lasater, J. (1995). 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: A yoga

journal book. New York, NY: Bantam Dell.

Mist, S., Firestone, K., & Jones, K. D. (2013). Complementary and alternative exercise for

fibromyalgia: A meta-analysis. JPR Journal of Pain Research, 247-260. doi:10.2147/jpr.s32297

National Fibromyalgia Association’s Home Page: Join us here. (n.d.). Retrieved August 06,

2016, from http://www.fmaware.org/

Page, J. L., & Page, L. L. (2014). Mudras for Healing and Transformation (Second ed.).

Sebastopol, CA: Integrative Yoga Therapy.

Page, J. L., & Page, L. L. (2005). Yoga toolbox for teachers and students: Yoga posture cards for

integrating mind, body & spirit: A powerful tool for healing. Shelby, NC: Integrative Yoga Therapy.

Rudrud, L., EdD. (n.d.). Gentle Hatha Yoga and Reduction of Fibromyalgia-Related Symptoms:

A Preliminary Report. International Journal of Yoga Therapy, 22, 2012th ser., 53-57.

Siegel, R. D. (2010). The mindfulness solution: Everyday practices for everyday problems. New

York: Guilford Press.

Yunus, M. B. (2007). Fibromyalgia and Overlapping Disorders: The Unifying Concept of

Central Sensitivity Syndromes. Seminars in Arthritis and Rheumatism, 36(6), 339-356. doi:10.1016/j.semarthrit.2006.12.009

 

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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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