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
As practitioners, we understand the value of a yoga practice for multiple systems. Yoga improves cardiovascular function, pulmonary function, improves flexibility, builds strength, improves balance, and cultivates resiliency. Prenatal yoga is deemed safe and widely practiced. Beyond not laying prone after the first trimester, what are modifications for practicing yoga while pregnant? Is there any evidence to demonstrate if specific yoga postures are safe from both the maternal and fetal perspective?
Polis et al set out to determine the safety of specific yoga postures using vital signs, pulse oximetry, tacometry, and fetal heart rate monitoring. The patients were diverse in age, race, BMI, gestational age, parity, and yoga experience. Exclusionary criteria included preeclampsia, placenta previa, bleeding in the 2nd or 3rd trimester, gestational diabetes, BMI greater than 35 and other medical conditions that presented contraindications.
The maternal and fetal responses were tested in 26 yoga postures. The selected postures, much like most yoga classes, offered a variety of physical positions. The standing, seated, twists and balancing postures chosen were: Easy Pose, Seated Forward Bend, Cat Pose, Cow Pose, Mountain Pose, Warrior 1, Standing Forward Bend, Warrior 2, Chair Pose, Extended Side Angle Pose, Extended Triangle Pose, Warrior 3, Upward Salute, Tree Pose, Garland Pose, Eagle Pose, Downward Facing Dog, Child’s Pose, Half Moon Pose, Bound Angle Pose, Hero Pose, Camel Pose, Legs up the Wall Pose, Happy Baby Pose, Lord of the Fishes Pose and Corpse Pose.
Balancing postures were modified to decrease fall risk. Warrior 3, Tree Pose, Eagle Pose, and Half Moon Pose were performed at the wall or using a chair for support. The addition of a yoga block to bring the floor closer to the practitioner was used for Extended Side Angle Pose, Extended Triangle Pose, and Garland Pose.
Four poses that have previously been theorized to be contraindicated were studied in this group. These postures are Child’s Pose, Corpse Pose, Downward Facing Dog, and Happy Baby. No adverse reactions were discovered for this specific population during the intervention or in the 24 hour follow-up as reported by email.
Now that we have this data, what do we do with it?
We have the opportunity to educate our non-high-risk patients that the previously theorized contraindicated postures listed above were safe for the self-selected group in this study. Those who are in high-risk categories should understand that even though yoga is not a high impact activity, there should be clearance from the OB team to ensure expectant mothers are moving as safely as possible. With proper guidance, yoga is a safe form of exercise and stress reduction which can optimize physical and mental health during the prenatal period and prepare for birth.
Dustienne Miller is the author and instructor of Yoga for Pelvic Pain. Join her in Kansas City, MO on April 7, 2018 - April 8, 2018 to learn about treating interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia with a yoga approach.
Polis RL, Gussman D, Kuo YH. Yoga in Pregnancy. Obstet Gynecol 2015;126:1237–41
You have been treating a highly motivated 24-year-old woman with a diagnosis of Interstitial Cystitis/Painful Bladder Syndrome (IC/BPS). The plan of care includes all styles of manual therapy, including joint mobilization, soft tissue mobilization, visceral mobilization, and strain counterstrain. You utilize neuromuscular reeducation techniques like postural training, breath work, PNF patterns, and body mechanics. Your therapeutic exercise prescription includes mobilizing what needs to move and strengthening what needs to stabilize. Your patient is feeling somewhat better, but you know she has the ability to feel even more at ease in their day to day. Is there anything else left in the rehab tool box to use?
Kanter et al. set out to discover if mindfulness-based stress reduction (MBSR) was a helpful treatment modality for (IC/BPS). The authors were interested in both the efficacy of a treatment centered on stress reduction and the feasibility of women adopting this holistic option.
The American Urological Association defined first-line treatments for IC/PBS to include relaxation/stress management, pain management and self-care/behavioral modification. Second-line treatment is pelvic health rehab and medications. The recruited patients had to be concurrently receiving first- and second-line treatments, and not further down the treatment cascade like cystoscopies and Botox.
The control group (N=11) received the usual care (as described above in first- and second-line treatments). The intervention group (N=9) received the usual care plus enrollment in an 8-week MBSR course based on the work of Jon Kabat- Zinn. The weekly course was two hours in the classroom supplemented with a 4-CD guide and book for home meditation practice carryover. The course content included meditation, yoga postures, and additional relaxation techniques.
The patients who participated in the MBSR program reported improved symptoms post-treatment, and perhaps more notably, their pain self-efficacy score (PSEQ) significantly improved. All but one of the participants reported feeling “more empowered” to control their bladder symptoms.
As clinicians working so intimately with our patients, we are often given the privilege of bearing witness to the emotional pain of healing chronic, persistent pelvic pain. We understand how terribly frightening it is for our patients to feel like they will never get better and we see this come out sometimes as fear-avoidance, which has the potential to cascade further into other areas of the social sphere.
If we are able to encourage holistic methods of building strategies to handle the challenges of IC/BPS, our patients will be set up for success in ways beyond the treatment room. While we hope for immediate results in the form of pain relief (which five patients in the study did), we also can appreciate the strategy building for resiliency in the face of persistent pain. As a very strong woman said, “hope serves us best when we do not attach specific outcomes to it”.
Dustienne Miller is the author and instructor of Yoga for Pelvic Pain. Join her in Manchester, NH on September 7-8, 2019 or in Buffalo, NY on October 5-6, 2019 to learn about treating interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia with a yoga approach.
Kanter G, Kommest YM, Qaeda F, Jeppson PC, Dunivan GC, Cichowski, SB, and Rogers RG. Mindfulness-Based Stress Reduction as a Novel Treatment for Interstitial Cystitis/Bladder Pain Syndrome: A Randomized Controlled Trial. Int Urogynecol J. 2016 Nov; 27(11): 1705–1711.
I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).
From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).
People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.
Let’s talk briefly about Trauma Informed Approach
This is a (person), program, institution or system that:
The Tenets of Trauma Informed Approach
Trauma Specific Interventions
Types of trauma are varied but I usually treat survivors of emotional, verbal, sexual and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgement). Since most of my clinical experience include sexual and medical trauma survivorship, I try to reframe these experiences as potential Post Traumatic Growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.
First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation and other mechanisms of coping with the trauma. Have a plan ready for these patients.
Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:
After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Making healthy boundaries (with patients and others), taking time to decompress, creating healthy ritualistic behaviors, mindfulness/relaxation and somatic release (like yoga, massage or working out) is crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.
Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my new course implements evidenced based trauma sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma Informed Approaches of Safety, Trustworthiness and transparency, Peer support, Collaboration and mutuality, Empowerment, voice and choice and Cultural, historical and gender issues.
Join me in Trauma Awareness for the Pelvic Therapist, next available this March in Albany, NY.