Yoga as a Therapeutic

in Primary Care
Oct 14, 2016

Zahra Bardai
BSc MD CCFP (COE) MHSc FCFP RYT
 DISCLOSURES
FACULTY:
Dr. Zahra Bardai BSc MD CCFP (COE) MHSc FCFP RYT

RELATIONSHIPS WITH COMMERCIAL INTERESTS:

 Grants/Research Support: None
 Speakers Bureau/Honoraria:
Purdue Pharma Canada
Merck Canada
Pfizer Canada
Biovail Corporation (Science and Medicine
Canada)
Kinetic Konnection
 Consulting Fees: None
 Other:
Pri-Med Planning Committee
IHS Reviewer
 DISLOSURE of
COMMERCIAL SUPPORT
This program has received NO financial
support

This program has received NO in-kind

support

Potential for conflict(s) of interest:

NONE
 MITIGATING
POTENTIAL BIAS

 This session will focus on best

available evidence for information
presented

 Opinions of the speaker will be

identified as such
 MITIGATING
POTENTIAL BIAS cont.
 OBJECTIVES
Physiology of Yoga
 To introduce key concepts of yoga practice:
Breath
Posture
Stillness

 To review the physiology behind the

concepts of yoga and the science that
supports it

 To apply the key concepts of yoga to clinical

practice

 To discuss the practical considerations in

prescribing yoga as a therapeutic in primary
care
 DEFINITIONS…

A discipline which includes

breath control, simple
meditation, and the adoption of
specific bodily postures as
practiced for health and
relaxation
 KEY YOGA
CONCEPTS

Breath

Posture (Asana)

Stillness
FOUNDATIONS…
BREATH
 Physiology
of Breath
Respiration is divided into 4 major
functional events:

 Pulmonary ventilation
(air in and out between the atmosphere and the lung)

 Diffusion of O2, CO2

(between alveoli and blood)

 Transport of O2 and CO2

(between blood and tissues)

 Regulation of ventilation
(multifactorial)
-Textbook of Medical Physiology
Guyton and Hall 9th edition
Pulmonary
Ventilation
Diffusion
and
Transport of
O2 & CO2
 Acid Base Metabolism
Relative to Breath
 Accumulation of CO2 in the blood
affects blood pH
 Blood pH influences amount of O2
available for tissue diffusion and use
 Lungs release waste CO2 (acid) from
cellular metabolism
 Immediate regulation of acidity or
alkalinity of blood by increasing or
decreasing the speed and depth of
inhalation and exhalation
Transport of
O2 , CO2 and O2 disassociation curve:
the Bohr
Effect

The more CO2 present

in the blood the more
readily hemoglobin
releases O2 to the
tissues
 Pranayama…
Yogic Breath
 Cornerstone to yogic practice

 Vital force

 Usually involves decreasing RR by

elongation of inhalation and
exhalation
 Pranayama…
Yogic Breath
 Used to cool, or heat up the body

 Assists in releasing muscular tension

in the asanas (poses)

 Used as a cue (biofeedback) to achieve

ease in a posture

 Focuses the mind (mindfulness)

 Assists in relaxation
 Pranayama…
Yogic Breath
Dirga ( 3 Part Breath)
Ujjayi (Ocean Breath)
Inhalation/Exhalation
patterning
 e.g. 4-7-8
 Sithali
Kapalabhathi
Nadhi Sodahana
 The Muscles of
Pranayama
Pranayama occurs by engaging the
primary, secondary and accessory
muscles of respiration
Diaphragm
Intercostals
Abdominal muscles “core”
Pelvic floor muscles “pelvic
diaphragm”
Vocal chords/glottis “vocal
diaphragm”
Yoga Anatomy -Kaminoff and Matthews
1st Edition
 Applying Physiology
to Yogic Breath
 Dirga breath potentiates full use of IC
 Ujjayi breath potentiates full expulsion of
ERV
 Together improves use of VC

 Slowing down the RR induces hypercapnia,

mild respiratory acidosis that shift the O2
hemoglobin disassociation curve to the right;
increasing the tissue availability of O2

 Secondary effect of conditioning the primary

and secondary muscles of respiration
 Pranayama…
Case Vignette
 39 yo woman, self described as “high
strung” and a “worrier”

 Married mother of 2 boys ages 7 and

10.

 Neg psychiatric history.

 Recent knee injury (degenerative

meniscal tear, treatment with medical
management and physical rehab on
STD) has stretched coping ability.
 Pranayama…
Case Vignette cont.
 Younger son with history of febrile
seizures (last one 4 years prior),
 Son with witnessed seizure on
weekend requiring EMS
intervention- no complications, now
asymptomatic on appropriate
medical management and specialist
care
 Seen in office Monday for follow up
and you walk in on her having an
acute panic attack:
hyperventilating, fearful, pressured
tangential speech, tremors
 Pranayama…
Case Vignette cont.
Immediate management
options for panic attack:
a. SL lorazepam
b. Get her to breath into a
paper bag
c. Pranayama breath exercise
d. Shock her by slapping her
across the cheek
FOUNDATIONS…
POSTURES
 Muscle Physiology
Muscles used in Yoga Postures
Skeletal (voluntary)
 Smooth (involuntary)
 Cardiac (involuntary)

Skeletal muscular movement is the

culmination of multi-system
mechanisms resulting in muscle
contraction that can hold, shorten,
or elongate a muscle in a stable
position
 Types of Muscular
Contractions
Isometric
on contraction the muscle does
not shorten or lengthen

Concentric
on contraction the muscle
overcomes resistance and the
muscle shortens

Eccentric
on contraction the opposing
force on the muscle causes it to
lengthen under tension
 Isometric Contraction Concentric Eccentric
Contraction Contraction
( + isotonic) (- isotonic)
ACTION Holding Stability Shortening Lengthening
(static) (dynamic) (dynamic)
OUTCOME Increases strength of Muscle contraction Slow, controlled
muscle quickly against a load or contraction with
external force; muscle elongation
increases muscle against a load;
mass Strengthens muscles
and provides the
“brakes” to protect
joints

INDICA- Can be used to minimize Used to increase Rehabilitate

TIONS muscle atrophy in muscle strength; tendinopathies; can
immobilization; used early improves endurance be done with or
in rehabilitation for and power of a without resistance
activation of isolated muscle (e.g. Achilles
muscle groups tendinopathy with
drop heel exercises)
 Fascial Physiology
STRUCTURE:
 dense irregular connective tissue
that surrounds and connects every
muscle, and every single organ of
the body forming continuity
throughout the body

 Important integrative element in

human posture and movement
organization

Schleip, R. J Bodyw Mov Ther 2003;7(2):104-116

FUNCTION:
 Referred to as the “organ of form”
or “mechanical matrix”

 Fasciae transmits muscle force and

used in load bearing functions
FUNCTION cont.:
 Fasciae used as elastic spring for
oscillatory movement such as
walking, hopping or running when
supporting skeletal muscles contract
isometrically

 When impaired (injury, FM) there are

deformations in fascial stiffness and
possible tearing.

Schleip, R. J of Musc Pain 2010 18(4): 393-395

 Yoga and the Fascia

“lengthening of the muscle

and fascia in the context of
identifiable biomechanical
based core movement
pathways is an effective
way to restore both
structural and functional
integrity”
DellaGrotte J et al J Bodyw Mov Ther 2008 12; 231-245
 The Yoga Bandhas
aka Muscular Locks
“Body Locks” Pivotal in Asana
Practice

 Mula Bandha - engagement of the

perineum

 Uddiyana Bandha- engagement of

the abdominals and “core”

 Jalandhara Bandha-engagement of
the head and neck muscles
Picturing the
Bandhas…
 Engaging the Bandhas…

The Key Muscles of Hatha Yoga -Ray Long 3rd Edition

APPLYING
MUSCULAR/FASCIAL
YOGA CONCEPTS :
Warrior II POSE
ISOMETRIC
Core

CONCENTRIC
Hip Flexors

ECCENTRIC
Hip IR
Hip Adductors

FASCIAL
ENGAGEMENT
Spiralic Turning
Yoga Anatomy -Kaminoff and Matthews 1st Edition
 Posture…
Case Vignette
 27 yo man, self employed IT specialist
x 5 years
 Spends 8-14 hours/day on the
computer mostly from home
 Experiencing neck pain and burning
between the shoulder blades x 6
weeks
 Neg medical history
 No rx medications
 Takes prn dosing otc ibuprofen- helps
a little
 Posture…
Case Vignette
 On examination significant findings
are:
 Turtle neck posturing
(head forward, ears in front of shoulders,
with an exaggerated anterior curve in the
lower cervical vertebrae and an
exaggerated posterior curve in the
upper thoracic vertebrae leading to
lordosis lower cervical spine
K kyphosis upper thoracic vertebrae)

 Periscapular tender points bilaterally

 Posture…
Case Vignette

WHAT ADVICE WILL YOU GIVE HIM

ON POSTURE?
 In the sitting position, starting from the bottom,
the feet should be placed on the ground (or foot
rest if they don’t reach), hip distance apart with
the weight distributed evenly.
 Legs should be uncrossed. Knees should be bent at
a 90-degree angle, and positioned at the level of
your hips. The pelvis is kept in a neutral position
(avoid tilting).
 The back is long (imagine rising up through the
crown of the head), and the stomach muscles are
slightly engaged by bringing the navel closer to the
spine.
 Shoulders are brought back but not so much that
the back arches. Allow the arms to rest on the
table making sure that the forearms are positioned
parallel to the ground.
 Lastly, to position the head, the chin is brought
slightly down toward the chest and the ears lined
up over the shoulders.
http://www.goodnewstoronto.ca/2014/06/the-dos-of-
proper-posture-sitting-and-standing/
FOUNDATIONS…
STILLNESS
 Mindfulness

“The awareness that emerges

through paying attention in a
particular way, on purpose,
in the present moment and
nonjudgmentally to the
unfolding of experience
moment by moment”
Jon Kabat-Zinn 1994, 2003
“dispassionate, non-
evaluative and sustained
moment to moment
awareness of perceptible
mental states and processes”
-Grossman et al 2004

“a receptive attention to and

awareness of present events
and experience”
-Brown et al 2007
 Yoga Stillness
“Yoga is the cessation of movements
in the consciousness”
Pantajali, Sutra 1.2 ~200BC

“Yoga is defined as a restraint of

fluctuations in the consciousness.
[It] is the art and science of mental
discipline”
BKS Iyengar
Light on the Yoga Sutras of Patajali
1966
 Comparing Components
MINDFULNESS YOGA STILLNESS

Self regulated attention Clearing and quieting of mental

chatter

Moment to moment awareness Being present in the moment

via meditation techniques

Observation and acceptance Letting go of non-serving

without trying to change or preconceptions “acceptance and
judge surrender”

Enhancement of personal Bringing awareness to the body

engagement with a resultant and breath
experience of flow (optimal
psychological state)
Neurophysiology of
Mindfulness
NETWORKS TO CONSIDER:
A. Default network
—ventral cortex
—automatic self evaluative
—primitive emotional thinking
—continuous cycling of thought
—self reinforces
—self attribution of external event
“negative narrative sticks”
Neurophysiology of
Mindfulness
B. Attentional network
—Pre/frontal cortex, parietal cortex,
thalamus, temporal parietal
junction, frontal eye fields,
colliculus, anterior cingulate
cortex, lateral ventral cortex, basal
ganglia
—subdivided into alerting,
orienting and executive control
networks
Neurophysiology of
Mindfulness
C. Salient network
—dorsal anterior cingulate,
ventrolateral prefrontal cortex,
anterior insula
—attentional control function of
relevant immediate stimulus
—activation of salient network:
activation of default network
redirects/redeploys default network
signals executive network to act
 Bottom Line:

 Paying attention in the

moment changes the way the
brain thinks
 Awareness of a stimulus,
without engagement leads to
acceptance

“ Notice what you

notice and let it go”
Malinowski, P. Frontiers in Neurosc 2013; 7:8
The story of the ice cream cone
and the raisins
 The Key Muscles of Hatha Yoga -Ray Long
3rd Edition
Human physiology, body kinetics and
neural plasticity literature supports yoga
principles of Breath
Posture
Stillness
Recommending Yoga...
Yoga is Indicated in…

Chronic LBP (mechanical) Stress

Sciatica (Piriformis) Anxiety/Depression
Osteoarthritis Insomnia
Rheumatoid Arthritis Chronic pain
Tendonitis Pre/Post Natal care
Pelvic Floor Dysfunction Diabetes
Fibromyalgia Hypertension
Chronic headache (tension) Obesity
Concussion Cancer support
 Caveats…
 Variety of Yoga styles, intensities and
durations used in studies, however,
different styles studied follow similar
principles and no one was found to be
superior.
 Yoga’s emphasis on strength,
flexibility breathing and focused
awareness may be more important
than specific type of yoga
 User factors- i.e. use of postures,
breath work, intrinsic motivation,
user expectations
 Instructor factors- i.e. style, focus,
training
 Intrinsic study limitations
Can Yoga be Harmful?
Cramer H, Krucoff C, Dobos, G. Adverse Events
Associated with Yoga: A Review of Published
Case Reports and Case Series. PLOS ONE Oct
2013 (8):10 e75515 www.plosone.org

 35 case reports and 2 case series (total 76

cases)
RESULTS:
 10 cases had medical preconditions,
mainly glaucoma and osteopenia.
 Pranayama, hatha yoga, and Bikram yoga
were the most common yoga practices;
 headstand, shoulder stand, lotus position,
and forceful breathing were the most
common yoga postures and breathing
techniques associated with injury.
 Of the 76 adverse events:
27 msk
14 nervous system;
9 eyes.
15 full recovery
9 partial recovery
1 no recovery
1 died.
 Study Conclusions

“As any other physical or mental practice,

yoga should be practiced carefully under the
guidance of a qualified instructor. Beginners
should avoid extreme practices such as
headstand, lotus position and forceful
breathing [kapalabathi].

Individuals with medical preconditions should

work with their physician and yoga teacher to
appropriately adapt postures; patients with
glaucoma should avoid inversions and patients
with compromised bone should avoid forceful
yoga practices.”
Do Mind-Body Practices
Affect Health Care
Utilization?
Š Stahl JE, Dossett ML, Lajoie AS et al.
Relaxation Response and Resiliency Training
and Its Effect on Healthcare Resource
Utilization. PLOS One Oct 2015
http://dx.doi.org/10.1371/journal.pone.0140212
Š Retrospective Study (use of Research Patient
Data Registry)
n=4453 intervention group
n= 13 149 matched control group
Š Intervention:
relaxation response and resiliency
training (3RP): meditation, mindfulness,
social support, cognitive skills training,
+ve psychology to reduce stress response
RESULTS:
Š 43% reduction billable
encounters (outpt, urgent
care, ER, hospitalizations) for
intervention group in all
functional and clinical
encounter categories (
p<0.0001)

Š Rough estimated average cost

savings of $1500 - $60
200/pt/year (US)
Š Yoga is grounded in
accepted medical physiology
Š Yoga has clinical application
for many common medical
conditions
Š Yoga has a low rate of
adverse events
Š Yoga can reduce health care
utilization and thus health
care costs
Writing a “Yoga Rx”

No evidenced consensus

Exercise prescription
literature and current
practice standards in
counseling PA
/recommending physical
rehabilitation
PA GUIDELINES FOR CANADIAN
ADULTS
 150min/week

 Bouts of 10min

 MOD-VIGOROUS INTENSITY
AEROBIC PA

 Muscle & bone strengthening

2 days /week

 65+ yrs add activity that

enhances balance and
prevents falls
http://www.exerciseismedicine.ca
 What Style of Yoga to
Recommend?
All yoga styles involving
physical postures are
derived from Hatha Yoga
Common Western Styles…
Anusara Iyengar
Ashtanga Kripalu
Bikram Viniyoga
Moksha Sivananda
Vinyasa/Power Yin
Kundalini Restorative
 Yoga Therapy

 Individual approach
 Functional recovery focus
 Based on breaking down yoga
postures, progressive movements and
breath work
 Use of props for adaptation and
progression
 Achieving emotional, psychological or
physiological goal of the individual
 Finding a Yoga
Therapist
IAYT
International Association of Yoga Therapists
Accreditation of yoga therapy
training programs
Voluntary Registry
http://iayt.site-
ym.com/search/custom.asp?id=11
56
Increasing number of PT/RYT
offering yoga therapy
 Alternative Yoga
Resources…
 Referring to “non-athletic” styled
yoga studios
 Finding established studios with
beginner foundation classes
 Specific Studio Introductory offers
 Passport to Prana
https://www.passporttoprana.com
 Take Home Message

Yoga’s positive outcomes in

the treatment of chronic
disease management can be
attributed to improved core
strength, stabilization,
flexibility and to
mindfulness practices
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