Yoga Therapy UPMASA 33 rd Annual Grand Convention Hilton Union - - PowerPoint PPT Presentation

Yoga Therapy

UPMASA 33rd Annual Grand Convention Hilton Union Square, San Francisco, CA

Enrico G. Camara M.D. FAPM UPCM ‘81

DISCLOSURE:

I’m on the shy side.

Learning Objectives

• 1. To describe and explain the history, principles

and practice of yoga in the USA.

• 2. To recognize the major benefits and risks of

yoga therapy.

• 3. Integrate the use of yoga, where applicable,

into a treatment plan for patient care.

2016 Yoga in America Study

• 36 million practitioners (up from 20.4 million in 2012)
• 14-M > 50 yo. 28% male.
• Reasons cited include flexibility, stress relief and fitness
• 34% of Americans are somewhat or very likely to practice

yoga in the next 12 months

• Practitioners are 20% more likely to say things like “I have

a good sense of balance,” “good dexterity,” “good range of motion,” or “give back to the community” than non- practitioners.

Yo-Goat

Kabayo-ga

Definition of Yoga

Yoga = “yoke” “union”

Body Mind

= small self (ego)

GOD (SELF)

Realization

Five Sheaths/ Levels of Existence: Bliss (Balance) Knowledge Mental Energy Physical Five Disruptors (Stressors): Ignorance (of true Self) Strong Desire (attachments) Strong Aversions Sense of separateness (ego) Fear (especially of Death) Symptoms: mental pain, anguish, turmoil, despair, tremors, irregular breathing, general nervousness, and anxiety

Yoga Definition (psycho-physiology) SELF

Prescription: 8 Limbs

• Abstentions
• Observances
• Postures
• Breath (Life-Force) Control
• Sense-withdrawal
• Concentration
• Meditation
• Contemplation – Bliss
• Definition of Yoga includes all 8 Limbs.

Yoga Therapy

• Yoga therapy is the process of

empowering individuals to progress toward improved health and well-being through the application of the philosophy and practice of yoga.

• IAYT

Yoga Therapy

• Yoga as integrative practice: body, mind,

spirit: to prevent and treat dis-ease

• Different from just taking a yoga class; but a

yoga class can be therapeutic

• Can be used for a variety of physical and

mental conditions

• Provides a supportive role to modern

medicine and integrates spiritual aspects

History of Yoga in the USA

Key Historical Events Yoga in USA

• 1893: Vivekananda

(disciple of Sri Ramakrishna) gave speech at World’s Fair in Chicago with the central message of commonality in humanity, a vision of global unity

• 1920: Yogananda comes

with same message to speak at Congress for Religious Liberals in Boston: “ religion is universal and one” and that everyone shares the aspiration of attaining happiness (bliss).

Limitations from Immigration Acts

• Immigration Act of 1917: essentially barred

immigration from the Asia-Pacific region

• Exclusions added based on challenges and needs of

states (laborers for rail, iron, plantations)

• Immigration Act of 1924: established quotas (e.g. 100

in 1925 for East Indians)

• Luce- Celler Act of 1946: quota of 100 Filipinos and

100 East Indians (allowed Filipinos to naturalize)

• Immigration and Nationality Act of 1965: beginning of

liberalization and non-discrimination against non- northern Europeans

History Yoga Therapy USA

• 1925: Yogananda relocates to LA
• 1928: Lecturing in Florida: banned “due to complaints

from husbands.” he was considered a ‘colored man’ acting in capacity of a teacher to white women. He returns to India dis-illusioned.

• 1930s: Columbia University: epicenter of hatha yoga in

the USA: Dr. Josephine Rathbone: PE Dept professor: techniques of progressive relaxation using yoga

• 1936: Yogananda relocates back to USA
• 1940s up: American students return after studying yoga

in India

• 1960s up: Other established yoga teachers from

different traditions/ lineages

History of Yoga as Therapy

Patanjali Sutras

• 196 aphorisms: first codification of yoga

practice

• Date unknown: 500 BCE to 300 BCE
• Main message: inner balance by

identifying with Self as Spirit (Divinity/ Pure Consciousness) via control of the mind

• Began more as a spiritual, meditative

practiced passed on through a lineage of teachers

Buddha Bose

Yoga Therapy

Benefits and Risks

Research Limitations

• No study has incorporated all 8 Limbs/ Parts of a Yoga Practice
• Limited to Postures and/or Breathing Exercises and/ or

“Meditation”

• More concentration exercises or relaxation vs. meditation
• Use of self-selected populations and/ or inappropriate control

groups

• Large variation of levels of experience and teaching ability of

yoga teachers;

• No double-blind studies
• Yoga interventions not described in detail in order to be

replicated

• Use of only self-report measures
• Large variation in “dosing”

Yoga Practices

(Postures-Relaxation, Breathing, Meditation) Mind-Body Awareness

Mindfulness Attention Concentration/ Cognition Self/Social awareness

Self-Regulation

Emotional Regulation Stress Regulation Resilience Equanimity Psychological Self-efficacy

Physical Fitness

Flexibility Strength Balance Cardiovascular Respiratory Function Physical Self-efficacy

Improved Physical and Mental Health, Performance, Behaviors

Mood, Well-being, Psychological Disorders, Substance Use Disorders, Positive Behaviors, Relationships, Cognitive-Academic Performance, Quality of Life

Yoga vs. Exercise

• PNS dominates
• Slow dynamic and static movements
• Low risk of injuring muscles and

ligaments

• Energizing
• Balanced activity of opposing muscle

groups

• Noncompetitive, process-oriented
• Subcortical regions of brain

dominate

• Internal awareness predominates
• SNS dominates
• rapid forceful movements
• higher risk of injury
• Fatiguing
• imbalanced activity of muscle

groups

• competitive, goal-oriented
• Cortical region of brain dominates
• External awareness predominates

Yoga Practices

(Postures-Relaxation, Breathing, Meditation) Mind-Body Awareness

Mindfulness Attention Concentration/ Cognition Self/Social awareness

Self-Regulation

Emotional Regulation Stress Regulation Resilience Equanimity Psychological Self-efficacy

Physical Fitness

Flexibility Strength Balance Cardiovascular Respiratory Function Physical Self-efficacy

Improved Physical and Mental Health, Performance, Behaviors

Mood, Well-being, Psychological Disorders, Substance Use Disorders, Positive Behaviors, Relationships, Cognitive-Academic Performance, Quality of Life

Activities that Stimulate PNS/ Vagus N.

• Singing, Chanting
• Slow, deep breathing
• Yoga
• Meditation and prayer
• Positive social relationships
• Laughter
• Probiotics
• Massage
• Intermittent Fasting
• Laying on R side
• Gargling, chewing

Touch Therapies

• Increases weight of premature babies by 47 %
• Reduces depression in patients with Alzheimer's disease
• Doubles likelihood children will speak in class
• Enhances attentiveness
• Reduces pain
• Reduces stress hormones
• Improves immune function

Vagal Nerve Stimulation Activities Can Help

• Anxiety disorders including OCD
• Depression
• Alzheimers
• Fibromyalgia
• Obesity
• Tinnitus
• Addiction
• Autism
• Metabolic syndromes
• CVS disease/ heart failure
• Irritable Bowel

Yoga Practices

(Postures-Relaxation, Breathing, Meditation) Mind-Body Awareness

Mindfulness Attention Concentration/ Cognition Self/Social awareness

Self-Regulation

Emotional Regulation Stress Regulation Resilience Equanimity Psychological Self-efficacy

Physical Fitness

Flexibility Strength Balance Cardiovascular Respiratory Function Physical Self-efficacy

Improved Physical and Mental Health, Performance, Behaviors

Mood, Well-being, Psychological Disorders, Substance Use Disorders, Positive Behaviors, Relationships, Cognitive-Academic Performance, Quality of Life

Mind-Body Awareness

• Three major senses through which we learn: visually, auditorily,

and kinesthetically (musculoskeletal system and viscera)

• Body awareness involves an attentional focus on and awareness
• f internal body sensations including propioception and

interoception

• It can be modified by mental processes including attention,

interpretation, appraisal, beliefs, memories, attitudes, affect

• Enhancing body awareness and non-judgmental mindfulness

thought to be key for all mind-body therapies (yoga, tai chi, etc.)

Body-Mind Awareness Meditation Can Help

• Anxiety disorders including OCD
• Depression
• Attention-Deficit
• Fibromyalgia
• Obesity
• Tinnitus
• Addiction
• Autism
• Metabolic syndromes
• CVS disease/ heart failure
• Irritable Bowel
• Asthma, COPD,
• etc

Yoga Practices

(Postures-Relaxation, Breathing, Meditation) Mind-Body Awareness

Mindfulness Attention Concentration/ Cognition Self/Social awareness

Self-Regulation

Emotional Regulation Stress Regulation Resilience Equanimity Psychological Self-efficacy

Physical Fitness

Flexibility Strength Balance Cardiovascular Respiratory Function Physical Self-efficacy

Improved Physical and Mental Health, Performance, Behaviors

Mood, Well-being, Psychological Disorders, Substance Use Disorders, Positive Behaviors, Relationships, Cognitive-Academic Performance, Quality of Life

Yoga Benefits by Organ System

Research Limitations

• No study has incorporated all 8 Limbs/ Parts of a Yoga Practice
• Limited to Postures and/or Breathing Exercises and/ or

Meditation

• More concentration exercises rather than meditation
• Use of self-selected populations and/ or inappropriate control

groups

• Large variation of levels of experience and teaching ability of

yoga teachers;

• No double-blind studies
• Yoga interventions not described in detail in order to be

replicated

• Use of only self-report measures
• Large variation in “dosing”
• No animal studies

Musculoskeletal System

(including Fascia/ Interstitium)

• Low back pain
• Osteoarthritis
• Rheumatoid Arthritis (includeding decrease in RF/ inflammatory markers)
• Cervical Pain
• Scoliosis, Kyphosis
• Chronic Fatigue Syndrome and Fibromyalgia
• Frozen Shoulder
• Mechanism: traction and creating space between joints; good postural habits-

alignment in 3 planes; alternating contraction/ stretching and relaxation; building spinal muscle strength; core strength; hinge at the hip and not at waist; increase

• f kinesthetic sense; stretching of fascia/ interstitium thought to help fluid in

space circulate removing waste and improving oxygenation. i.e. good for lymphatics and small blood vessels

Alignment Planes

Fascia

Neurological System

• Post-Stroke
• Chronic Pain Syndromes
• Traumatic Brain Injury
• Insomnia
• Peripheral Neuropathy
• Carpal Tunnel Syndrome
• Autism Spectrum and ADHD
• Mechanism: postural; balance; kinesthetic awareness; circulation;

mood; self-regulation- : becoming aware of what and how body feels and responds

Endocrine/ Metabolic Systems

• similar reductions in FBG when compared to exercise
• greater reduction in LDL when compared to exercise
• greater increase in HDL when compared to exercise
• significant improvements in at least one measure of

body size and composition, including reductions in body weight

• Some similar effects to caloric restriction (BMR, body

temp, etc)

• Some studies only used pranayama (breathing

exercises) with same positive benefits; but asanas provided additive effect

Cardiovascular System

• Reduces risk factors like dyslipidemia, hypertension, diabetes,

smoking, mental stress, obesity

• Reduces oxidative stress, inflammation, pro-coagulant states
• Useful in cardiac rehabilitation: yoga part of Dean Ornish

lifestyle program in reversing heart disease. This program covered by Medicare and private insurers like Blue Cross Blue Shield

The Aorta is the body’s largest blood vessel - running down the spine from the heart to the abdomen - and its stiffness is linked to not only the heart but the brain as well.

Aorta Reflected Wave in Older and Younger Individual

Respiratory System

• Can be beneficial in asthma and COPD
• Studies focus more on breathing exercises and

meditation vs. asanas

• Awareness of posture and breath
• Awareness of abdominal and thoracic breathing

Dermatological System

• Skin conditions affected by stress and inflammation

(e.e. acne, psoriasis)

• Heat may aggravate certain conditions (rosasea)
• Anti-aging facial yoga
• Being comfortable in your own skin
• Skin as an excretory organ
• Support of connective tissue underlying the skin and

improvement of blood circulation

• Skin as energy exchange membrane

Mental Health

• Modest effects for anxiety and depression;

but not when meeting clinical diagnostic criteria

• Long-term benefits unknown
• Note: goal of 8 limbs of yoga practice is

“Bliss” and many practitioners report this sense of ‘peace’ and ‘balance’ with a regular practice

• Effects related to ability to self-regulate body

and mind, stress management, and relaxation response

Other Applications

• Cancer- role in immune system and coping
• Geriatrics- looking at markers of stress,

aging, cognitive decline

• OB- Gyn- fitness during pregnancy, post-

partum depression and anxiety

• Pediatrics- ADHD, school performance
• End of Life Care

Characteristics Baseline 12 wks Change from baseline to 12 wks (diff. 95% C.I.) Effect p value Primary endpoints: cardinal biomarkers of cellular aging Oxidative stress ROS (RLU/min/104 neutrophils) 194.3 (164, 224.5) 0.7 <0.0001 TAC (mmol Trolox equiv/L) −1.16 (−1.9, −0.41) 0.4 <0.001 DNA damage 8OH2dG (pg/mL) 235.3 (72.73, 397.8) 0.22 <0.01 Telomere attrition Telomerase activity (IU/cell) −1.05 (−1.68, −0.41) 0.3 <0.001 Telomere length (IU/cell) −0.08 (−0.61, 0.45) 0.02 0.069 Secondary endpoints: biomarkers associated with cellular aging Cortisol (ng/mL) 22.51 (7.6, 37.42) 0.3 <0.01 Interleukin (IL6) (pg/mL) 1.22 (0.47, 1.97) 0.3 <0.001

• Endorphins (ng/mL)

−2 (−3.22, −0.77) 0.3 <0.001 BDNF (ng/mL) −17.4 (−19.48, −15.32) 0.7 <0.0001 Sirtuin (ng/mL) 40.64 ± 11.6 −13.95 (−23.41, −4.49) 0.5 <0.01 BMI (kg/m2) 2.66 (0.56, 3.12) 0.4 <0.01

Yoga and Markers

• f stress, aging,

and inflammation

Other Applications

• Cancer- role in immune system and coping
• Geriatrics- looking at markers of stress,

aging, cognitive decline

• OB- Gyn- fitness during pregnancy, post-

partum depression and anxiety

• Pediatrics- ADHD, school performance
• End of Life Care

Quiet Time: Center for Wellness and Achievement in Education

• Improved school-wide GPA
• Increased attendance
• Decreased suspensions and school violence
• Reduced student anxiety and psychological distress
• Increased self-esteem
• Higher standardized test scores
• Decreased burnout and stress in teachers and

administrators

• Increased emotional intelligence
• Increased coping ability in adults

Relationship of Yoga with Ayuvedic Medicine

Three Gunas or Qualities

Safety

• Yoga is generally low-impact and safe for healthy people when practiced

appropriately under the guidance of a well-trained instructor.

• Mostly, joint and muscle injuries and/or injuries related to falls

* Overall, those who practice yoga have a low rate of side effects, and the risk of serious injury from yoga is quite low. However, certain types of stroke as well as pain from nerve damage are among the rare possible side effects of practicing yoga.

• Women who are pregnant and people with certain medical conditions,

such as high blood pressure, glaucoma, and sciatica should modify or avoid some yoga poses.

Possible Injuries/ Risks

• Peripheral neuropathy (from holding poses too long)
• Vertebro-basilar artery insufficiency/ strokes (shoulder stands/

head stands)

• Contraindication: history of aneurysms, FMD

Possible Injuries/ Risks

• Knee injury
• Disc herniation (following disc surgery)
• Other injuries/ heart events common to
• ther physical activities
• Case report of ‘kundalini psychosis’
• Symptoms related to dehydration and

electrolyte imbalance in heated yoga

• Increased ‘body only’ focus and increased

compulsive behavior related to the practice of yoga

• Abuse of teacher-student relationship

8 Limbs in the Practice of Yoga

• Abstentions (from harm, lying, stealing, greed, craving and addictions)
• Observances (Purity, Contentment, Living within means, Study,

Devotion: i.e. spiritual/ meaning of life for them, etc)

• Postures
• Breath Control
• Sense-withdrawal
• Concentration
• Meditation
• Contemplation – Bliss

Clients

• Adults
• Must have a yoga asana practice (any style)
• Willing to learn meditation as ultimate ‘therapeutic’ tool
• +/- Thai Yoga Massage
• Referrals from yoga studios and yoga students and integrative

medicine physician

• Main reasons: weight loss; back pain; stress; other

musculoskeletal conditions

• Most seeking balance in life to deal with physical or mental

dis-ease and/ or relationship issues

Poses

• Bikram-method/ Hot Yoga
• Ashtanga
• Iyengar
• Vinyasa forms
• Yin Yoga
• Heat: added thermal benefit esp. Far-

Infrared Heat

Physiologic Effects of FIR

• Penetrates 4 – 5 cm into dermis of skin,

elevating temp, and dilating capillaries, stimulating blood circulation, increasing metabolism, promoting tissue regeneration

• Produces water molecule and atomic

resonance which increases enzymatic activity and toxin release

• Increases macrophage activity which helps

immune system

• Creates heat for tissues
• Promotes release of nitric oxide

Breath Control

• Prana or Life Force is more than
• xygen.
• Brings greater discipline to physical

body;

• Incorporated as part of asana practice
• r stand-alone breathing exercises

Sense-withdrawal

• This is done by drawing the senses away

from their respective objects: in-turning.

• The key is detachment; not detachment

from objects, but detachment from our reactions to these objects, and our sensory perceptions of the objects

• When sense withdrawal has been

mastered, concentration, meditation and bliss are very easily attained.

concentration

• One-pointedness by gaining conscious

control over your mental faculties

• A self-constriction of the mind which

requires effort; vs meditation which is an effortless holding of the mind to its object with an expansiveness

• Attention without tension
• Mind naturally wanders; observe and

gently bring it back to object of concentration

Meditation

• meditation is not just a technique but also

a basic approach to life

• It is the ultimate psychology
• It is a feeling of an awareness of the Self
• r Pure Consiousness
• Concentration: Mind is restricted to one
• bject, with effort, causing one-

pointedness

• Meditation: effortless enlarging of the field
• f awareness

Movement from concentration to meditation

• stream of thought
• thought

thought thought thought

(feeling)

• Concentration: light meditation: deep

meditation

Meditation Management

• Make meditation enjoyable; make it a habit
• Go slow and build on it: “yard by yard,

yoga is hard; inch by inch, it’s a cinch!” it does not matter how long you meditate but how deeply

• Even just starting with a few minutes a day

but key is making it a habit at a usual time and place

• It doesn’t matter how often the mind

wanders, but how gently you bring it back

Contemplation

• “those who say, do not know. Those

who know, do not say” – Lao Tzu

• An extension of meditation and is an

action you perform

• Consciousness without an Object: Pure

Subjectivity

• The experience of God-consciousness

“In the beginning nothing comes, in the middle nothing stays, in the end nothing goes.”

• Milarepa, Tibetan 12th-Century Yogi and Sage

Arbiters of “Truth”

• Religion
• Science
• Law
• News
• SELF- Awareness and SELF- Realization:

Knowing “truth” from inside out maintains homeostasis

Mahalo Q and A