The popularity of yoga continues to rise with over 36 million yogis living in the United States of America and over 300 million practitioners worldwide. Yoga has several therapeutic effects that make it a beneficial addition to home exercise programs for practitioners and personal practice.
Dustienne Miller discussed some of the benefits of yoga in her March blog (March 8, 2022 - A yoga practice can change your neuroanatomy!). These benefits extend beyond the musculoskeletal system and include improved mood and depression, changes in pain perception, improved mindfulness and associated improved pain tolerance, and the ability to observe situations with emotional detachment.
The physical benefits are well documented in several research studies and include improved flexibility, strength, and stability as well as enhanced respiratory and cardiovascular function. Supporting documentation also shows that yoga can help alleviate the symptoms of chronic pain. Dustienne Miller shared that in a study by Villemure et al, they determined “that the insula-related interoceptive awareness strategies of the yoga practitioners being used during the experiment correlated with the greater intra-insular connectivity...concluding that the insular cortex can act as a pain mediator for yoga practitioners.”
Restorative yoga shares the many benefits seen in other styles of yoga and can also be a great addition to home programs for pelvic rehab practitioners. Kate Bailey shared in her interview with The Pelvic Rehab Report (August 31, 2021 – Faculty Interview: Kate Bailey) that restorative yoga “focuses on the lesser-known aspects of the yoga platform: breath, restorative practice, and a bit of meditation. I have clients all the time who struggle with meditation because their nervous systems aren’t ready for it. So we look at breathing and restorative yoga both as independent alternatives, but also as a way to get closer to meditation.. giving the clinicians another skill for their own rest practice can be useful when feeling tired, overwhelmed, or burned out. “
But what does this mean? Let’s look at some of these aspects a bit closer:
Improving mood and sleep: This includes depression, anxiety, and even stress or other mood disorders. Consistent yoga practice can lead to significant increases in serotonin levels coupled with decreases in the levels of monoamine oxidase, an enzyme that breaks down neurotransmitters and cortisol(1). Yoga can inhibit the areas in the brain responsible for fear, aggressiveness, and rage (posterior or sympathetic area of the hypothalamus) – while simultaneously stimulating the rewarding pleasure centers in the median forebrain and other areas leading to a state of bliss and pleasure. This inhibition results in lower anxiety, heart rate, respiratory rate, blood pressure, and cardiac output (2).
Think about it. Deep breathing calms the nervous system. This promotes relaxation. The more relaxed you are then the better the chance of having a good night’s sleep. Consistent yoga practice can also assist sleep quality by increasing melatonin and reducing hyperarousal (3). Pratyahara, or a turning inward of the senses, allows downtime for the nervous system and can be encouraged by yoga poses such as savasana (corpse pose) and pranayama (breathing exercises/control.
Reduced Chronic Pain: Asana and meditation have been shown to reduce chronic pain including reduced pain from arthritis, back pain, and other chronic conditions while also improving balance and increasing proprioception(1). Yoga sessions can take our joints through a full range of motion. This squeezes and soaks areas of cartilage not often used and provides fresh nutrients, oxygen, and blook to the joints. Otherwise neglected areas of cartilage in the joints would wear out, exposing bone, which can lead to arthritis and chronic pain. At the same time, yoga is gentle on the body and consistent practice can strengthen the connective tissues that surround the bones and joints.
Effects on Cancer Patients: Yoga cannot cure cancer, but it can reduce stress and improve physical, emotional, and spiritual wellness. There is supporting research that the growth of cancerous tumors can be exacerbated by stress(4). This same study found that consistent yoga practice could decrease post-chemotherapy-induced frequency and intensity of nausea and the intensity of anticipatory nausea and vomiting. In 2018 Lin et al provided new research showing that restorative yoga can decrease depression in cancer survivors; improve symptoms of anxiety, depression, and pain symptoms in cancer patients; and help patients manage the toxicity of cancer treatments (5). In addition, yoga has a fundamental emphasis placed on mindfulness and acceptance of your body and its limitations.
Kate Bailey likes to joke about lying on the floor, but really, it is not a joke at all. Lying on the floor for 15 minutes is savasana. She shares that “Savasana is a wakeful resting and a practice of relaxation response. It seems easy: you always have access to a floor. You don’t need anything fancy. Aside from the neuroregulatory benefits of rest, savasana also gives the postural muscles a break. It allows the hip flexors to re-lengthen and the cervicothoracic junction to realign.”
Let’s take a moment to close with a savasana (did you know that a 5-minute savasana is recommended for every 30 minutes of yoga?). This pose can calm the central nervous system, aid the digestive and immune systems, reduce headaches, fatigue, and anxiety while lowering blood pressure and calming the mind, and reducing stress.
Take a moment and lay on the floor with your arms and legs open wide and relaxed (starfish style), supported by a bolster, or you may want to place your hands gently over your chest or your stomach. Now gently still your body. Release your breath and be present. Be completely aware of the moment. Let your mind and body go for a few moments.
Restorative Yoga for Physical Therapists with instructor Kate Bailey
This course will provide the basis for experiencing and integrating restorative yoga into physical therapy practice. Restorative yoga is an accessible practice that can teach patients (and practitioners) how to rest systematically, for short periods of time, on a regular basis to encourage the parasympathetic nervous system to balance with the sympathetic nervous system for improved neuroregulation. Topics include the difference between meditation and restorative yoga, and how they can support each other in order to support the ability to drop into relaxation. Restorative postures, each taking 20-30 minutes are offered prior to the live meeting so that participants can experience what a patient might experience when restorative yoga is a component of their home program. Then in the live course participant experiences, questions, and strategies on how to reduce barriers to relaxation so that patients can integrate this practice into their lifestyle will be discussed. There will also be live labs for breathing techniques and specific meditations that may be helpful to patients working with an unregulated nervous system.
Yoga for Pelvic Pain with instructor Dustienne Miller
This course offers an evidence-based perspective on the value of yoga for patients with chronic pelvic pain by focusing on two of the eight limbs of Patanjali’s eightfold path: pranayama (breathing) and asana (postures) - and how they can be applied for patients who have hip, back and pelvic pain. A variety of pelvic conditions will be discussed including interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Lecture topics include the role of yoga within the medical model, contraindicated postures, and how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge.
This week, faculty member Kate Bailey sat down with Holly Tanner to discuss her course Restorative Yoga for Physical Therapists.
Hi Kate, can you tell us about the course you have designed Restorative Yoga for Physical Therapists?
My name is Kate Bailey and I am a pelvic floor physical therapist. I’ve been a pelvic floor PT going on4-5 years now. Before that, I’ve been a pilates instructor for 20 years and taught yoga for over a decade. This course is a culmination of all of my experiences both with the yoga, pilates, and the pelvic floor population from kiddos through adulthood. It allows us to use the techniques from the yoga and pilates philosophies to support people in their healing process from pelvic pain and also just in their bodies.
What can participants expect to learn when they come to the course?
I wrote this course when the pandemic started. My whole intention was to make the didactic information self-paced and watch the videos as often as you want kind of course. This way, when we have dedicated time together it’s a lot more about discussion and me guiding people through the labs, and in turn, they can guide their colleagues or patients. It is designed so I’m not spending a lot of time lecturing to a screen and our time dedicated to each other is more about a conversation. I want people to learn about the information in their own time, marinate in it a little bit, and then come with questions.
How do you feel that restorative yoga fits in with the care we provide to our patients with pelvic health conditions?
The restorative yoga component to me is really special because it’s one of the only times we prioritize rest, and not doing, and sitting with ourselves. Not necessarily trying to get strong, or trying to get more flexible. It’s really about allowing our bodies to be. Sometimes that is being in a little bit of discomfort. Sometimes that is just being with the exhaustion that I think we all have a little bit of. Just learning how to be with ourselves for 8, to 12, to 15 minutes and see that as a really productive part of our treatment plan.
How does trauma-informed care influence your course?
One of the things that I highlight in the course is how much trauma occurs in and around the home. So when we’re asking patients to do a home program one of the discussion points we have in the course is “what if the home is inherently triggering or unsafe?” How can we use concepts of graded exposure to get someone from needing a lot of sensory things, like lights on, windows locked, facing the window, eyes open to slowly getting people toward a little bit more safety. If that is not a possibility, finding another location and strategizing how we can prioritize our own safety and our own ability to relax rather than saying I must relax.
The other component of trauma in the course is the unveiling of how prevalent trauma is. In pelvic health, we talk a lot about sexual trauma because we are dealing a lot with the pelvic floor region and the genitals. One of the things I think we sometimes might be able to speak to more is the little subversive types of trauma. Whether it is emotional trauma, whether it is neglect, whether it is transgenerational trauma or intersectionality trauma…
There’s this other component in yoga that is coming out now that is the trauma that has been handed down through the yoga lineages. What I think is not understood is that a lot of people who practice yoga in a deep way have significant trauma from yoga. The question then is how do we reclaim a practice that is so lovely, done with care and kindness and non harming, for people who have maybe experienced it in a very harmful way – and introduce it as a non-harming, caring, compassionate method for people who haven’t experienced it. The whole idea is about how do you be in rest in your body and in empowerment.
Can you give an example of how a pelvic PT or OT would fit restorative yoga into their practice?
As PTs and Ots we are starting to bring mindfulness in, a lot, to our programming in terms of some of the work from Jon Kabat Zen on how great meditation is for so many things. There is still a question of “How do I put this in my plan of care?” The great thing about this class is that we can speak directly to this. Let's say that you are in a hospital-based scenario, you can give restorative yoga to someone n a hospital bed very easily. They’re not going anywhere and what a great thing to give them: a breathing practice, a concentration practice, and a rest practice.
For someone in private practice, such as orthopedics, this is the type of practice where maybe you’re not giving pelvic floor strengthening if someone has a large degree of overactivity in their pelvic floor. But they still need something to do at home, or they need something to do at the office. Maybe restorative yoga is a little bit too far out there for the patient. Maybe they don’t have a space they can lie down on the floor. That’s when we can say, ok how can we then transfer a pelvic floor restorative yoga posture to a desk situation? Can you cross your legs on your chair and lean forward, and modify it that way.
Then there is this component of the class that is all about breathing. I think we know in pelvic health how wonderful and how great breath-work can be and so some of these techniques can be used as ‘secret exercises’ in your everyday life in addition to being a dedicated practice. We talk about all of that in class.
Watch the full interview with Kate Bailey at the Herman & Wallace YouTube Channel:
Join Kate to learn more about including restorative yoga into your practice with Restorative Yoga for Physical Therapists this year. Courses are scheduled for:
Dustienne Miller, CYT, PT, MS, WCS instructed the H&W remote course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. You can find Dustienne Miller on Instagram at @yourpaceyoga
Research demonstrates multiple benefits of a yoga practice that extend beyond the musculoskeletal system. These benefits include improved mood and depression, changes in pain perception, improved mindfulness and associated improved pain tolerance, and the ability to observe situations with emotional detachment.
Do the brains of yoga practitioners vs non-practitioners look different?
A study by Villemure et al looked at the role the insular cortex plays in mediating pain in the brains of yoga practitioners. They included various styles of yoga to capture the essence of yoga across multiple styles - Vinyasa, Ashtanga, Kripalu, Sivananda, and Iyengar.
Rewind back to neuroanatomy class - remember the insular cortex? The insular cortex is responsible for sensory processing, decision-making, and motor control by communicating between the cortical and subcortical aspects of the brain. The outside inputs include auditory, somatosensory, olfactory, gustatory, and visual. The internal inputs are interoceptive (Gogolla).
Villemure et al found several interesting objective differences. The practitioners had increased grey matter volume in several areas of the brain. This increase in grey matter specifically in the insula correlated with increased pain tolerance. The length of time practiced correlated with increased grey matter volume of the left insular cortex. Additionally, white matter in the left intrainsular region demonstrated more connectivity in the yoga group.
Other differences were seen in strategies utilized to manage pain. Most folks in the yoga group expected their practice would decrease reactivity to pain, which it did. The yoga group used parasympathetic nervous system accessing strategies and interoceptive awareness. These strategies were breathwork, noticing and being with the sensation, encouraging the mind and body to relax, and acceptance of the pain. The control group strategies were distraction techniques and ignoring the pain.
The authors determine that the insula-related interoceptive awareness strategies of the yoga practitioners being used during the experiment correlated with the greater intra-insular connectivity. Therefore, the authors conclude that the insular cortex can act as a pain mediator for yoga practitioners.
The more strategies our patients have for pain management, the better! Yoga is one of several non-invasive modalities our patients can add to their healing toolbox.
Yoga for Pelvic Pain was developed by Dustienne Miller to offer participants an evidence-based perspective on the value of yoga for patients with chronic pelvic pain. This course focuses on two of the eight limbs of Patanjali’s eightfold path: pranayama (breathing) and asana (postures) and how they can be applied for patients who have hip, back, and pelvic pain.
A variety of pelvic conditions are discussed including interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Other lectures discuss the role of yoga within the medical model, contraindicated postures, and how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge.
Gogolla N. The insular cortex. Current Biology. 2017; 27(12): R580-R586.
Villemure C, Ceko M, Cotton VA, Bushnell MC. Insular cortex mediates increased pain tolerance in yoga practitioners. Cereb Cortex. 2014 Oct;24(10):2732-40. doi: 10.1093/cercor/bht124. Epub 2013 May 21. PMID: 23696275; PMCID: PMC4153807.
This week The Pelvic Rehab Report sat down with Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI to discuss her career as a physical therapist and upcoming course, Restorative Yoga for Physical Therapists, scheduled for September 11-12, 2021. Kate’s course combines live discussions and labs with pre-recorded lectures and practices that will be the basis for experiencing and integrating restorative yoga into physical therapy practice. Kate brings over 15 years of teaching movement experience to her physical therapy practice with specialties in Pilates and yoga with a focus on alignment and embodiment.
Who are you? Describe your clinical practice.
My name is Kate Bailey. I own a private practice in Seattle that focuses on pelvic health for all genders and ages. I work under a trauma-informed model where patient self-advocacy and embodiment are a priority. My dog, Elly, assists in my practice by providing a cute face and some calming doggy energy. My patients often joke that they come to see her just as much as to see me, which I think is great. In addition to being a physical therapist, I’ve been teaching Pilates for nearly 20 years and yoga for over 10. They are both big parts of my practice philosophy and my own personal movement practice
What books or articles have impacted you as a clinician?
I have a diverse library of Buddhist philosophy, emotional intelligence, trauma psychology, human behavior, breathwork/yoga, and sociology and, of course, a bunch of physical therapy pelvic floor books. I also love a children’s book on emotional regulation or inclusion, even for adults. One of my favorite finds is the Spot series that gives kiddos different ways to use their hands to help deal with different emotions. I’ve used it for adults who need physical self-soothing options. There are so many, and I find that it's the amalgamation of information that really impacts my practice the most.
How did you get involved in the pelvic rehabilitation field?
I have a deep interest in the human experience and how culture and dissociation create mass-disembodiment and how hands-on work can be profound in how we experience our body. Pelvic rehab allowed me the opportunity to work more closely with people on areas that bring up the most shame, disembodiment, and trauma, and therefore have some pretty amazing possibilities to make an impact not only in their lives but how they act in culture. In many ways, I see my work in pelvic rehab as a point of personal activism in creating a more embodied, empowered, and powerful culture.
What has your educational journey as a pelvic rehab therapist looked like?
I knew I wanted to go into pelvic health from my second year in PT school. I’ve always been at bit…well, let’s call it driven. I did an internship with great therapists in Austin and then only considered full-time pelvic floor positions once licensed. I took as many courses as I could handle in my first couple years of practice, which worked well for me, but understandably is not the right path for all those entering this field for a number of reasons. I went through the foundational series, and then into visceral work as well as continued my yoga and Pilates studies. I continued my education in trauma and emotional intelligence which is both a personal and professional practice. I found that a blend of online coursework and in-person kept me satisfied with my educational appetite.
What made you want to create your course, Restorative Yoga for Physical Therapists?
I was a yoga teacher long before I became a PT. When I found my way into the specialty of pelvic floor physical therapy, this particular part of my yoga teaching became incredibly useful for patients who had high anxiety, high stress, and difficulty with relaxation and/or meditation. This course was a way for me to share some of my knowledge of restorative yoga with the community of health care providers, where it could not only be used as a means of helping patients, but also as a means to start valuing rest as a primary component of wellbeing.
What need does your course fill in the field of pelvic rehabilitation?
Learning about yoga as a full practice and understanding that it has many components is very useful in deciding which component would be a good match for a pelvic health patient. Is it strengthening from an active practice? Is it meditation or pranayama (breath manipulation)? Or is it supported rest? This particular course focuses on the lesser-known aspects of the yoga platform: breath, restorative practice, and a bit of meditation. I have clients all the time struggle with meditation because their nervous systems aren’t ready for it. So we look at breathing and restorative yoga both as independent alternatives, but also as a way to get closer to meditation. Learning how to help people rest, the different postures, how to prop, and how to dose is an important component of this class. As a bonus, giving the clinicians another skill for their own rest practice can be useful when feeling tired, overwhelmed, or burned out. All this under a trauma-informed, neuro-regulation-focused model is a lovely way to deepen one’s physical therapy practice.
What demographic, would benefit from your course?
People who are stressed out or who work with people who are stressed out. In particular, clinicians who work with people who have pelvic pain or overactivity in their pelvic floors.
What patient population do you find most rewarding in treating and why?
I love working with female-identifying patients that struggle with sexual health or those who are hypermobile and trying to figure out movement that feels good. I love working with all genders generally and do so regularly. There’s nothing quite like helping a male-identifying patient find embodiment and understanding of their pelvis in a new way. I think for me, working to dismantle female normative structures for those identifying as female, particularly in the realm of sexual health feels inspiring to me because it combines physical, emotional, spiritual health with going against the cultural standards of how those identifying as women fit into society, and being able to sit with the trauma of all types that so many people face.
What do you find is the most useful resource for your practice?
A pelvic floor model is great. The most important part of my practice is a conversation about consent, not only for internal work but for everything I offer during visits and also for patients to understand that they can give or retract consent with any medical provider for just about any service. Emergency procedures are a smidge different, but I hope my patients walk away with the understanding that the medical community is here to serve their embodied experience. My newest favorite resource is a series of metal prints that depict the emotional intelligence grid used in the RULER syllabus. I have a magnet that patients can use to identify how they are feeling and help develop their language for emotional and then somatic or interoceptive knowledge.
What has been your favorite Herman & Wallace Course and why?
There was nothing quite like PF1. I don’t think I’ll ever forget it. The instructors were Stacey Futterman Tauriello and Susannah Haarmann. I was still in grad school prepping for my internship and ended up being the model for labs which falls squarely in line with my upbringing as a dancer who wanted to understand everything from the inside out. It was a challenging weekend on pretty much every level. I went through phases of dissociation and total connection. It made me realize that my decision to enter health care after having a career in movement was the right one.
What lesson have you learned from a course, instructor, colleague, or mentor that has stayed with you?
Meet the patient where they are at first and validate that they live in an incredibly intelligent body. I think sometimes it’s so exciting to see the potential that patients have because, as clinicians, we’ve seen the progress of others. In yoga, there is a practice of the beginner’s mind. It asks the student to sit with an empty cup of knowledge and experience each practice with the curiosity of someone just being introduced to yoga. I have knowledge that may be helpful to patients. Patients have so much knowledge of their own body from their life experiences, some of which are conscious and so much of which is subconscious. The fun part is seeing how my experience and their experience match (or don’t sometimes) to then assess how to craft the care plan.
If you could get a message out to other clinicians about pelvic rehab what would it be?
That it's so much more than pelvic rehab. We get to talk to people about things that aren’t talked about and normalize the human experience. Pelvic rehab gives safety to patients to experience their bodies in all the sensations that come from having a nervous system: from sadness to joy to relief to fear. It's all in there and when we learn about those sensations from pelvic rehab, my hope is that it can flood into other areas of life.
What is in store for you in the future as a clinician?
Refining, learning, and seeing what else comes. Hoping to publish a book of cartoon organs shortly. But most importantly to create a safe space for patients to feel cared for and supported in my corner of Seattle.
Kate Bailey (She/Her)
Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI curated and instructs the remote course on Restorative Yoga for Physical Therapists, which is scheduled for September 11-12, 2021. Kate brings over 15 years of teaching movement experience to her physical therapy practice with specialties in Pilates and yoga with a focus on alignment and embodiment. Kate’s pilates background was unusual as it followed a multi-lineage price apprenticeship model that included the study of complementary movement methodologies such as the Franklin Method, Feldenkrais, and Gyrotonics®. Building on her Pilates teaching experience, Kate began an in-depth study of yoga, training with renown teachers of the vinyasa and Iyengar traditions. She held a private practice teaching movement prior to transitioning into physical therapy and relocating to Seattle.
Without a doubt, these past couple of years have been tough with this global pandemic of a virus that caused major shifts in how we work, play, learn and socialize. Wherever you live on this planet, it is nearly impossible not to have been affected by the stress and trauma that the Covid-19 virus has created. Just like with any other stressor, the first step of management is recognition. Check, done.
Step two involves making conscious choices about how we want to live. This is where we have some options, including self-care. “Self-care” is one of my least favorite phrases. Not because at its core, self-care is not important. But because it's another thing on an overflowing to-do list and can create even more of a sense of imbalance, lack of accomplishment, and self-defeat. Yet, learning how to manage stress is a skill we all need: individually and communally.
However, there is a step before stress management that we need to address first. Interoception, defined by Porges, Ph.D., is the process that describes both conscious feelings and unconscious monitoring of bodily processes by the nervous system. As a clinician, this is a key aspect of every single patient care plan. I am a big fan of embodied decision making, and yet our somatic intelligence (or interoceptive skills) is widely underdeveloped.
Just as emotional intelligence is getting some wonderful development, through the work of researchers and educators like Marc Brackett, Ph.D. of Yale Center for Emotional Intelligence, our wellbeing and access to wellness are dependent on our ability to understand the sensations and signals throughout our body and then make a choice. This is important since you can’t make an embodied choice (step 2) before you have the data (step 1 - interoception). An example would be to imagine if you never felt the sensation of hunger, or the ‘hangry’ feeling when it’s been too long since the last boost of nourishment…how would you determine that you are hungry?
So, what to do? Many of us (clinicians and patients alike) live in a world full of overstimulation, productivity requirements, and constant stress. To develop interoception, finding little periods of stillness can be really useful. In yoga, there is a dedicated practice called pratyahara. Translated from Sanskrit to English as ‘withdrawal of the senses.’ The senses, in this case, includes all the sense organs: sight, smell, sound, touch, taste, movement (vestibular), and spatial placement (proprioception). Traditionally this is an aspect of meditation.
In my experience as a yoga teacher and physical therapist, I find this practice more accessible in the restorative yoga practice. It can take some graded exposure, but at the heart of the restorative yoga practice is stillness, darkness, silence, and support from props so that the body doesn’t have to do anything. These are also the essential components described by Herbert Benson, MD in his work on the Relaxation Response. In his work, he showed the relaxation response to be effective in decreasing heart and respiration rate triggering the benefits of the vagal nerve; which we are learning has so much to do with our ability to neuroregulate and participate in individual and communal stress management.
Restorative yoga is a practice of wakefully resting. Immordino-Yang et al, studied the brain in functional MRI when individuals were wakefully resting. The study found that during wakeful rest (without a meditative component where the brain has a task of concentration) the brain goes into a mode of neural processing called default mode. In default mode, the brain supports memory recall, imagining the future, and developing socio-emotional intelligence. In relationship to stress management, this is so important because it re-centers us, and allows for connection for even more neuroregulation.
For my patients, I often joke about lying on the floor. Really, it is not a joke at all. Lying on the floor for 15 minutes is savasana. Savasana is a wakeful resting and a practice of relaxation response. It seems easy: you always have access to a floor. You don’t need anything fancy. Aside from the neuroregulatory benefits of rest, savasana also gives the postural muscles a break. It allows the hip flexors to re-lengthen and the cervicothoracic junction to realign.
It is pretty great, and really accessible for most people. For those who are not comfortable flat, that’s where the props used in restorative yoga come into play. As physical and occupational therapists, we are so well primed to help people learn how to support their bodies in rest to get the benefits of rest.
Burnout, the Secret to unlocking the stress cycle by Emily Nagoski, Ph.D. and Amelia Nagoski, DMA
Polyvagal Theory, Stephen W Porges, PhD
Immordino-Yang et al. - Perspectives on Psychological Science - 2012
The Relaxation Response by Herbert Benson, MD, and Miriam Z Klipper
Portions of this blog are from an interview with Dustienne Miller. Dustienne is the creator of the two-day course Yoga for Pelvic Pain. She passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life.
Have you noticed when you are afraid or don’t want to feel something you hold your breath? Imagine what it's like to have daily pain that limits function and how that could impact rib cage, abdominal and pelvic floor expansion. Dustienne Miller discusses this in her remote course, Yoga for Pelvic Pain, upcoming on July 31 - August 1, 2021. Her course focuses on two of the eight limbs of Patanjali’s eightfold path: pranayama (breathing) and asana (postures) and how they can be applied for patients who have hip, back, and pelvic pain.
Dustienne explains "We teach our patients how breathing patterns inform our digestion, our spine, our emotional state, our pelvic floor, etc. It’s one of the most powerful tools we have to inform our system that we are safe. Despite this knowledge, we will often find ourselves holding our breath or breathing in non-optimal ways without even realizing it." Dustienne focuses her practice on introducing yoga to patients within the medical model. Yoga can be included in pelvic rehabilitation in so many ways, including incorporating yoga home programs as therapeutic exercise and neuromuscular re-education (both between visits and after discharge).
Pelvic conditions that can be positively impacted by yoga are interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Treatment for these conditions often involves an individualized approach that may include both pharmacologic therapies (prescription drugs, analgesics, and NSAIDs) and nonpharmacologic interventions such as exercise, muscle strength training, cognitive behavioral therapy, movement/body awareness practices, massage, acupuncture, and nutrition.
A systematic review of the 2017 clinical practice guidelines evaluated 14 randomized controlled trials and found that yoga was associated with lower pain scores (1). Similarly, in 2020 there was a review of 25 randomized controlled trials that examined the effects of yoga on back pain. Out of these trials, 20 studies reported positive outcomes in pain, psychological distress, and energy (2).
The great thing about yoga is that the asanas (postures) can be modified to accommodate your strength, experience, and health conditions. An example of this is the Downward Facing Dog pose. There are so many ways to made Downward Facing Dog work for your body. Use straps, the wall, or the plinth/countertop to provide support for your body as needed, which might look different each day.
Some folks think you need to be flexible to have a yoga practice. Dustienne stresses "What is necessary is to be flexible with understanding that every day might feel different. If you are in an active pain flare your practice will look different than on the days you are feeling better. That can be a challenging aspect of a mindful practice - embracing that every day is different. Have the courage not to judge yourself, but to celebrate that you are meeting your needs with kindness."
People have been doing yoga for thousands of years. It is a mind-body and exercise practice that combines breath control, meditation, and movements to stretch and strengthen muscles. Join Dustienne Miller in Yoga for Pelvic Pain on July 31 - August 1, 2021, to learn more about incorporating yoga into your clinical practice.
No prior experience with teaching yoga is required to attend the course. However, all participants must possess a working knowledge of pelvic pain conditions and foundational rehabilitation principles.
Rachna Mehta, PT, DPT, CIMT, OCS, PRPC is the author and instructor of the new Acupressure for Pelvic Health course. She is Board certified in Orthopedics, is a Certified Integrated Manual Therapist and is also a Herman and Wallace certified Pelvic Rehab Practitioner. An alumni of Columbia University, Rachna brings a wealth of experience to her physical therapy practice with a special interest in complex orthopedic patients with bowel, bladder and sexual health issues. Rachna has a personal interest in various eastern holistic healing traditions and she noticed that many of her chronic pain patients were using complementary health care approaches including Acupuncture and Yoga. Building on her orthopedic and pelvic health experience, Rachna trained with renowned teachers in Acupressure and Yin Yoga. Her course Acupressure for Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional and energy body. Rachna is a member of the American Physical Therapy Association and a member of APTA’s Pelvic Health section.
According to the National Center for Complementary and Integrative Health (NCCIH), a branch of NIH, pain is the most common reason for seeking medical care1. Over the last several decades there has been an increasing interest in safe and efficacious treatment options as our healthcare system faces a crisis of pills and opioid use. Among complementary medicine approaches, Acupressure has come forth as an effective non-pharmacologic therapeutic modality for symptom management.
Acupressure is widely considered to be a noninvasive, low cost, and efficient complementary alternative medical approach to alleviate pain. It is easy to do anywhere at any time and empowers the individual by putting their health in their hands. Acupressure involves the application of pressure to points located along the energy meridians of the body. These acupoints are thought to exert certain psychologic, neurologic, and immunologic effects to balance optimum physiologic and psychologic functions2. Acupressure can be used for alleviating anxiety, stress and treating a variety of pelvic health conditions including Chronic Pelvic Pain, Dysmenorrhea, Constipation, digestive disturbances and urinary dysfunctions to name a few.
Acupressure uses the same points as Acupuncture; however, it is a very active practice in that we can teach our patients potent acupressure points as part of a wellness self-care regimen to manage their pain, anxiety and stress in addition to traditional physical therapy interventions. Traditional Chinese Medicine (TCM) believes in Meridian theory and energy channels which are connected to the function of the visceral organs. There is emerging scientific evidence of Acupoints transmitting energy through interstitial connective tissue with potentially powerful integrative applications through multiple systems.
Acupressure has also been used with various types of mindfulness and breathing practices including Qigong and Yoga. Yoga is an umbrella term for various physical, mental, and spiritual practices originating in ancient India, Hath Yoga being the most popular form of Yoga in western society. Yin Yoga, a derivative of Hath Yoga, is a much calmer meditative practice that uses seated and supine postures, held three to five minutes while maintaining deep breathing. Its focus on calmness and mindfulness makes Yin Yoga a tool for relaxation and stress coping, thereby improving psychological health3. Yin Yoga facilitates energy flow through the meridians and can be used for stimulating acupressure points along specific meridian and energy channels bringing the body to its physiological resting state.
As Pelvic health rehabilitation specialists, we are uniquely trained to combine our orthopedic skills with mindfulness based holistic interventions to improve the quality of life of our patients. We can empower our patients to recognize the mind-body-energy interconnections and how they affect multiple systems, giving them the tools and self-care regimens to live healthier pain free lives. Please join me on this evidence-based journey of holistic healing and empowerment as we explore Acupressure and Yin Yoga as powerful tools in the realm of energy medicine to complement our best evidence-based practices.
1. Pain: Considering Complementary Approaches published by National Center for Complementary and Integrative Health.2019.
2. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.
3. Daukantaitė D, Tellhed U, Maddux RE, Svensson T, Melander O. Five-week yin yoga-based interventions decreased plasma adrenomedullin and increased psychological health in stressed adults: A randomized controlled trial. PLoS One. 2018;13(7).
Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI joins the Herman & Wallace faculty with her new course on Restorative Yoga for Physical Therapists, which is launching in remote format this June 6-7, 2020. Kate brings over 15 years of teaching movement experience to her physical therapy practice with specialities in Pilates and yoga with a focus on alignment and embodiment. Kate’s pilates background was unusual as it followed a multi-lineage price apprenticeship model that included study of complementary movement methodologies such as the Franklin Method, Feldenkrais and Gyrotonics®. Building on her Pilates teaching experience, Kate began an in depth study of yoga, training with renown teachers of the vinyasa and Iyengar traditions. She held a private practice teaching movement prior to transitioning into physical therapy and relocating to Seattle.
Yoga is a common term in our current society. We can ﬁnd it in a variety of settings from dedicated studios, gyms, inside corporations, online, on Zoom, at home, and on retreat. The basic structure of a typical yoga class is a number of ﬂowing or non ﬂowing postures, some requiring balance, some requiring going upside down, and many requiring signiﬁcant mobility to achieve a certain shape. At the end of these classes is a pose called savasana, corpse pose (or sometimes translated for comfort as ﬁnal resting pose). In this pose, which is often a treat for students after working through class, students lie on the ground, eyes closed, possibly supported by props, and rest. It is perhaps the only other time in the day when that person is instructed to lie on the ﬂoor in between sleep cycles.
Savasana is one of many restorative yoga postures. In the work created and popularized by Judith Hanson Lasater, PT, PhD1, restorative yoga has taken a turn away from the active physical postures, breath manipulations and meditations that are commonplace in how we think of yoga. She has focused on rest and the need for rest in our current climate of productivity, poor self-care, and diﬃculty managing stress and pain.
In a dedicated restorative yoga class (not a fusion of exercise then rest, or stretch then rest… which are really lovely and have their own beneﬁts), a student comes to class, gathers a number of props, and is instructed through 3 to 5 postures, all held for long durations to complete an hour or longer class. Consider what it would look like to do 3 things over one hour with the intent of resting. It is quite counter-culture. Students have various experiences to this type of practice, but overtime many begin to feel the need for rest (or restorative practice) in a similar way that one feels thirsty or hungry.
We know the beneﬁts of rest: being able to access the ventral vagal aspect of the parasympathetic nervous system is what Dr. Stephen Porges2 suggests supports health, growth and restoration. There is impact on the ventral vagal complex in the brainstem that regulates the heart, the muscles of the face and head, as well as the tone of the airway. To heal, we need access this pathway. To manage stress, we need to access this pathway. To be able to choose our actions rather than be reactionary, we need to access this pathway. Restorative yoga is an accessible method that may be a new tool in a patient’s tool box to help manage their nervous systems.
1. Relax and Renew: Restful Yoga for Stressful Times by Judith Hanson Lasater PT, PhD
2. Polyvagal Theory by Stephen W Porges PhD
Dustienne Miller MSPT, WCS, CYT is a Herman & Wallace faculty member, owner of Your Pace Yoga, and the author of the course Yoga for Pelvic Pain. Join her in Columbus, OH this April 27-28, to learn how yoga can be used to treat interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. The course is also coming to Manchester, NH September 7-8, 2019, and Buffalo, NY on October 5-6, 2019.
How does a yoga program compare to a strength and stretching program for women with urinary incontinence? Dr. Allison Huang1 et al have published another research study, after publishing a pilot study2 on using group-based yoga programs to decrease urinary incontinence. Well-known yoga teachers Judith Hanson Lasater, PhD, and Leslie Howard created the yoga class and home program structure for this research study and the 2014 pilot study. The yoga program was primarily based on Iyengar yoga, which uses props to modify postures, a slower tempo to increase mindfulness, and pays special attention to alignment.
To be chosen for this study, women had to be able to walk more than 2 blocks, transfer from supine to standing independently, be at least 50 years of age, and experience stress, urge, or mixed urinary incontinence at least once daily. Participants had to be new to yoga and holding off on clinical treatment for urinary incontinence, including pelvic health occupational and physical therapy.
28 women were assigned to the yoga intervention group and 28 women were assigned to the control group. The mean age was 65.4 with the age range of 55-83 years of age.
The control group received bi-weekly group class and home program instruction on stretching and strengthening without pelvic floor muscle cuing or relaxation training.
The yoga program met for group class twice a week for 90 minutes each and practiced at home one hour per week. The control group met twice a week for 90 minutes with a one-hour home program every week. Both groups met for 12 weeks.
Both groups received bladder behavioral retraining informational handouts. The information sheets contained education about urinary incontinence, pelvic floor muscle strengthening exercises, urge suppression strategies, and instructions on timed voiding.
The yoga program included 15 yoga postures: Parsvokonasana (side angle pose), Parsvottasana (intense side stretch pose), Tadasana (mountain pose) Trikonasana (triangle pose), Utkatasana (chair pose), Virabhadrasana 2 (warrior 2 pose), Baddha Konasana (bounded angle pose), Bharadvajasana (seated twist pose), Malasana (squat pose), Salamba Set Bandhasana (supported bridge pose), Supta Baddha Konasana (reclined cobbler’s pose), Supta Padagushthasana (reclined big toe pose), Savasana (corpse pose), Viparita Karani Variation (legs up the wall pose), and Salabhasana (locust pose).
Women in the yoga intervention group reported more than 76% average improvement in total incontinence frequency over the 3-month period. Women in the muscle stretching/strengthening (without pelvic floor muscle cuing and relaxation training) control group reported more than 56% reduction in leakage episodes.
Stress urinary incontinence episodes decreased by an average of 61% in the yoga group and 35% in the control group (P = .045). Episodes of urge incontinence decreased by an average of 30% in the yoga group and 17% in the control group (P = .77).
The take away? We know behavioral techniques have been shown to improve quality of life and decrease frequency and severity of urinary incontinence episodes.3 Couple this with our clinical interventions, and our patients have a way to reinforce the work we do in the clinic by themselves, or socially within their community. Yoga can be another tool in the toolbox for optimizing pelvic health.
1) Diokno AC et al. (2018). Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern Med.1;178(10):1333-1341. doi: 10.1001/jamainternmed.2018.3766.
2) Huang, Alison J. et al. (2019). A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in a single-center randomized trial. American Journal of Obstetrics & Gynecology. 220(1) 87.e1 - 87.e13. doi: 10.1016/j.ajog.2018.10.031
3) Huang, A. J., Jenny, H. E., Chesney, M. A., Schembri, M., & Subak, L. L. (2014). A group-based yoga therapy intervention for urinary incontinence in women: a pilot randomized trial. Female pelvic medicine & reconstructive surgery, 20(3), 147-54.
When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.
Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).
This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.
Cushing et al., (2018) recently published online a study testing the impact of yoga on post-9/11 veterans diagnosed with PTSD. The participants were >18 years old and scored at least 30 on the PTSD Checklist-Military version (PCL-M). They participated in weekly 60-minute yoga sessions for 6 weeks including Vinyasa-style yoga and a trauma-sensitive, military-culture based approach taught by a yoga instructor and post-9/11 veteran. Pre- and post-intervention scores were obtained by 18 veterans. Their PTSD symptoms decreased, and statistical and clinical improvements in the PCL-M scores were noted. They also had improved mindfulness scores and decreased insomnia, depression, and anxiety. The authors concluded a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms.
Domestic violence, sexual assault, and unimaginable military experiences can all result in PTSD. People in our profession and even more likely, the patients we treat, may live with these horrors in the deepest recesses of their minds. Yoga is gaining acceptance as an adjunctive therapy to improving the symptoms of PTSD. The Trauma Awareness for the Physical Therapist course may assist in shedding light on a dark subject.
Walker, J., & Pacik, D. (2017). Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Medical Acupuncture, 29(4), 232–238.
Cushing, RE, Braun, KL, Alden C-Iayt, SW, Katz ,AR. (2018). Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Military Medicine. doi:org/10.1093/milmed/usx071