Friday Q&A: Modifying Poses for a Hip Replacement

Pose to Avoid for People with Posterior Lateral Hip Replacement

A reader left this question on our post Featured Sequence: Dynamic Reclined Hip Stretches (Rerun).

Q: What adaptation would you use for someone with a hip replacement?

A: To answer this question, we need to consider the type of hip replacement the yoga practitioner has had. Which type of replacement person has had is going to affect their asana practice.

To review from our post on total hip replacements and yoga, the basic categories of total hip replacement are:

1. posterior lateral approach
2. anterior lateral approach
3. anterior approach
4. minimally invasive anterior approach or minimally invasive posterior approaches

These are all different, but as far as hip precautions go there are no hip precautions for the anterior approaches.

In general, everyone who has a hip replacement should ask their surgeon what their post-operative physical limitations are and for how long. Make sure you learn how to safely get up and down from the floor so you don’t dislocate your new hip. And make sure that you learn the specific precautions associated with your category of hip replacement. The key is that you learn to identify what position your hip is in when you do your poses. Think of both legs when you do each side (don’t just focus on the surgical side).

In the more traditional posterior or posterior lateral approach there are limitations on hip flexion, adduction and internal rotation. That means that if you combine these three positions you are more apt to dislocate your prosthetic hip because the muscle support is weakened by the surgical procedure. Poses you might want to not do for approximately six months would be: Standing Forward Bend (Uttanasana), Eagle pose (Garudasana), Cow-Face pose (Gomukhasana), and Child’s pose (Balasana). Gentle backbends generally are okay for posterior/posterior lateral hips.

For anterior lateral hips the precautions will be very different. Typically hip extension and hip abduction will be affected and you don’t want to be aggressive in these combined movements. So start thinking about your backbends and standing poses. Remember that the position of the front and the back legs are very different in the standing poses. The front hip may be placed into positions of flexion and external rotation and abduction but the back hip may be in extension with external rotation.

For anterior hip replacement surgeries the doctor will typically tell you that you have no restrictions but that doesn’t mean you are going to jump back into your asana practice. The hip is going to be sore and painful because of the surgical trauma (though it is less in this procedure than some of the other ones I talked about because there is no actual muscle cutting in this procedure but the muscles are certainly stretched as they are moved for the surgery).

Now to Baxter's sequence, Dynamic Reclined Hip Stretches: To answer this question I combined hip surgeries into two categories; anterior and posterior approaches. That’s because functionally there isn't a whole lot of difference in precautions for each subcategories within the two main categories.

1. Deep Hip Flexion. 

Flexion Greater Than 90 Degrees

All four poses in the sequence involve deep hip flexion. The reason hip flexion works for low back discomfort is that the ilium rotates posteriorly when the knee and hip are flexed, and, conversely, the lumbar spinal curve is reversed and the back flattens. This often feels good because those tight low back extensor muscles are stretched.

However, with a hip replacement, flexion beyond 90 degrees often causes a "pinching" sensation in the groin region. If the hip replacement was an anterior approach there is no fear of dislocation but discomfort can certainly arise. However, with a posterior lateral approach, the position of deep hip flexion is not recommended due to dislocation risks. (Unfortunately there is no time when a hip replacement will not dislocate, but typically the high-risk time is 0-90 days post-operatively).

As a modification, you could try using a chair. Place your top leg on the chair so your calf is resting on the chair seat, and your hip and knee are bent at 90/90. Lengthen your bottom leg underneath the chair seat. This makes the pose more passive and this gentler approach might be the safer way to go. (I don't like teaching my students to “deeper” into a pose using overpressure with their arms because I think this is a potential way to cause injury. I believe that for muscle release to occur, you should take the joint to its pain-free position and breathe while statically holding the pose.)  

2. Hip and Knee Flexion with Abduction and External Rotation 

Position 2 in this sequence is a red light for a posterior lateral approach because two of the three dislocation movements are present: hip flexion beyond 90 degrees and, for some approaches, external rotation being limited due to how the hip might be fixed within the joint. So for this type of hip replacement, you could modify the pose with a chair, as recommended for position 1. After placing your top leg on the chair so your calf is resting on the chair seat, let your knee and thigh roll outward.

3. Knee to Chest Moving Over the Midline.

For a posterior lateral hip replacement, Position 3 should never be done! This is the full rendition of dislocation position, which is flexion with adduction and internal rotation. To get a similar stretch (the tensor fasca lata, lateral hip abductors or piriformis) I suggest a Jathara Parvartanasana variation. This pose is a reclined twist, with, in this case, two bent knees. Before coming into the pose, either place either a folded blanket between your thighs and legs down to your ankles or place a foam block between the knees. And place a bolster on the floor to support your legs after you come down so your legs don’t go all the way down to the floor.

Finally, the key concept is that regardless of the type of surgical approach, you need to learn to respect your hip and never push into pain. Posterior lateral hip replacements are more dislocation-prone than anterior hip replacement procedures but end-range overpressure will cause discomfort in anterior hip replacements. And, unfortunately, if the prosthesis is sized improperly, even trying to do the modifications I’ve recommended might still be uncomfortable. In that case, go back to your surgeon—or ask your student to go back to their surgeon—for some frank discussions on the specific dos and don'ts for their hip replacement.

—Shari 

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Side Plank Pose (Vastithasana) Could Reduce Spinal Curves in People with Scoliosis!

by Nina

Side Plank Pose (photo "borrowed" from Wall Street Journal)

I’ve been hearing for some time that a single yoga pose, Side Plank pose (Vasithasana), is particularly beneficial for people with scoliosis (see Friday Q&A: Scoliosis). In my post Late-Onset Scoliosis is Common in Older Adults, I wrote about a New York Times article that said that late-onset scoliosis, a condition I have myself, is actually more prevalent in adults than it is in adolescents. The author of that article, Jane Brody, is not a regular yoga practitioner, but she described a “yoga exercise” that was recommended to her after she found out about her late-onset scoliosis.

"Determined to minimize further shrinkage and to avoid pain and nerve damage, I consulted a physiatrist who, after reviewing X-rays of my misshapen spine, said the muscles on my right side, where the spinal protrusion is, were overdeveloped relative to the left. He prescribed a yoga exercise — a side plank — to strengthen the muscles on the left and exert enough of a tug on my spine to keep it from protruding farther to the right. He suggested that the exercise might even straighten the curve somewhat. And I myself had the same pose, Side Plank pose (Vasithasana) recommended to me by my chiropractor (yes, I have a chiropractor for my scoliosis—I don’t believe that yoga is the answer to everything), so I have incorporated this wonderful strengthening pose into my regular yoga practice."

Now a recent scientific study, which was reported in the Wall Street Journal article Study: Doing the Side Plank Reduced Spinal Curving in Scoliosis Patients, found that for a small group of patients with scoliosis (21 women and four men ages 14 to 85) practicing this one pose resulted in a curve reduction of almost 50 percent among teenage practitioners and 38 percent for adults. Yes, they studied just this single yoga pose!

"In this study, we assess the possible benefits of asymmetrical strengthening of truncal muscles on the convex side of the scoliotic curve through a single yoga pose, the side plank pose, in idiopathic and degenerative scoliosis."

For this particular study, they advised the participants to do the pose on one side only, "with the convexity downward." For information on the original study, see Serial Case Reporting Yoga for Idiopathic and Degenerative Scoliosis.

While this study of Side Plank pose is, like so many other scientific studies of yoga, limited by the small number of participants being studied and the lack of control group, there is no question in our minds that this is an excellent strengthening pose. In his post Friday Q&A: Yoga for Surgically Repaired Scoliosis, Baxter mentioned Side Plank pose as one of the strengthening poses that he recommended for strengthening the muscles at the front, back, and sides of your body. Shari says the pose strengthens the serratus anterior, the obliques, the latisimus, quadratus the lumborum, the gluteus muscles, the fasciae latae, hamstrings, scapula stabilizers, teres minor and major, and then all the paraspinal muscle stabilizers. Wow that’s a lot of muscles! That's why we recommend this pose for anyone who wants to build upper body strength. And I’m betting that strengthening those paraspinal muscles (the muscles all along the spine) is particular beneficial for people with scoliosis.

So today seems like a good day to review our instructions for how to practice this pose. For people who don’t yet have the strength to do the pose on the floor, we provide the option of doing the pose with one hand on the wall. You can practice the wall version regularly until you build up the strength to do the floor version.

Side Plank Pose on the Floor

1. Start by taking Downward-Facing Dog (Adho Mukha Svanasana) pose.

1. From Downward-Facing Dog, swing your shoulders forward almost into Plank position while keeping your hips lifted.

3. Make your right arm stronger by contracting the muscles of the arm to the bone, and tip your heels to the right, bringing the outer edge of your right foot and the inner edge of your left foot to the floor, with your feet slightly apart.

4. Turn your chest away from the floor and bring your left hand onto your left hip. Since this takes a lot of strength, stay just few breaths at first, and gradually add more time with more practice.

5. To come out, swing back into Downward-Facing Dog pose

6.  Unless you are practicing on one side only as in the study, repeat the pose on the second side. Afterward, rest in Child’s pose a few breaths.

Side Plank Pose on the Wall 

1. Start with your right side to the wall. 

2. Reach your right arm out to your side, parallel with the floor, and place your palm on the wall with your fingers pointing up. Engage your right shoulder blade into your chest wall and down slightly towards your right waist.

3. Step both feet out away from the wall, until your right foot is positioned directly under your left shoulder.

4. If your balance is good, try bending your left knee and bringing your left foot into Tree pose (Vrksasana).

5. Take your left arm up and overhead, reaching strongly towards the wall with your left arm and shoulder blade, aligning it like the top arm in Extended Side Angle pose (Utthita Parsvakonasna). 

6. Unless you are practicing on one side only as in the study, repeat on the second side. 

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The Fifth Branch of Yoga: Pratyhara

by Ram

Alley near Pourville by Claude Monet

In my earlier posts on Ashtanga Yoga, I discussed the first four angas or steps (yama, niyama, asana, and pranayama), all of which enable practitioners to become more flexible, stable, and grounded in order to move easily into a regulated breath practice and to further develop inner focus and concentration. Pratyahara is step 5 of the 8 steps. Verse 2.54 in the Yoga Sutras describes pratyahara as: 

sva vishaya asamprayoge chittasya svarupe anukarah iva indriyanam pratyaharah

When the mental organs of senses and actions (indriyas) cease to be engaged with the corresponding objects in their mental realm, and assimilate or turn back into the mind-field from which they arose, this is called pratyahara. —Swami Jnaneshvara  

Most teachers and nearly all of the textual commentaries define pratyahara as “withdrawal of senses.” Our five senses serve as portals or gateways into our body, mind, and consciousness. We are what we taste, smell, see, hear and touch. It is through these senses that we absorb the world around us. If we take in harmonious impressions through our senses, we will in turn be healthier. If we take in that which is unhealthy, the mind and body suffer. If we are not aware about what we draw in through our senses, it can lead to physical and mental instability. The human body and mind can survive on low-quality sensory impressions but cannot thrive. In order to maximize life potential, each person must learn to live harmoniously with their environment through the five senses.

A human being as a whole is a combination of body, mind, and spirit—physical, mental (psychological), and spiritual dimension. When we ignore our connection with the last two dimensions and just think of ourselves as a physical body, we are primarily acting through our five senses. Thus, we are attracted more to material possessions and desires, and try to surround ourselves with them. As we continue to build more material desires, we start making wrong choices, and the frustration and stress that builds up triggers mental imbalance/fluctuations (vrittis), leading to physical instability.

So, to me, the definition of pratyahara is more than just “withdrawal of senses.” In this present world, working at a job, staying with a family, raising kids, etc., all require the coordinated use of the five senses. One cannot withdraw the senses from our daily life’s duties unless we give up on everything and retire to the mountains. So, I like to define pratyahara as “using our senses with total/complete awareness.” In my opinion, practicing pratyahara does not mean running away from a situation or suppressing the impression. Rather, it means being present in the middle of it, being aware of what it is and consciously not reacting but instead choosing how to respond.

The practice of pratyahara comes in handy even in the yoga room, whether we are setting ourselves to a silent meditation or practicing asana.Think about it—on the mat we are naturally but unconsciously using all five senses in our practice. Can you become more aware of how your senses are acting during practice? Are you inundated with lot of thoughts, action, and dramas about your practice or a specific pose? Or are you intimidated with your neighbor’s supposedly perfect pose? Do you hear a lot of chatter in your mind? Notice if your mind and senses are very busy with a lot of judgments about perfecting your practice or pose. In all these cases, practice pratyahara by gently shifting your impressions and start focusing on the practice or pose itself. Never judge yourself or others. In your asana practice, if your senses are drifting so your focus is more on a macho body or a slim, skinny body, you need to practice pratyahara. As BKS Iyengar aptly put it:

“It must not be just your mind or even your body that is doing the asana. You must be in it. You must do the asana with your soul.”

"To be in it" means being in the “zone” or being in “flow, ”and this requires cultivating the quality of pratyahara—to let go of the ego, including your body image, to feel open, grounded, calm, and finding your true self (see Positive Psychology vs. Yoga Philosophy). Every time you are “in” your yoga practice, you gain experience and inherently improve your skill level. Very soon, the practice takes your skill sets to a higher level and you are able to do more by challenging yourself further. You experience contentment and enjoy a sense of accomplishment. It’s a great positive spiral and it results in improved health and happiness.

You can think of pratyahara as a fulcrum that regulates external practices, such as asana and pranayama, and internal observances, such as dharana (focus) and dhyana (meditation), which are the next two limbs in the Yoga philosophy that I plan to discuss in future posts. Suffice to say that pratyahara exercises help to develop stillness of the mind as well. Meditation or stillness of mind requires for the senses to be regulated, and pratyahara is a powerful technique to induce complete physical, mental and emotional relaxation while maintaining awareness at the deeper levels. It is a state where the you are fully aware without being influenced by the senses. At this stage, the senses are not bringing in any impressions. The mind is quiet and, in that stillness, produces few or no thoughts at all. While all this may seem a difficult task, it is not impossible. Remember that we need to climb or conquer each limb to get to that moment. Even though it may take years to attain the ideal state of stillness or the “perfect pose,”there are benefits that can be experienced at every stage of our progress.

Thus, pratyahara is about going back to intention, rather than outcome. It is being aware of what we draw in through the five senses and returning to harmony. Once back in harmony, the body and the mind have no reason to communicate the imbalances. The body is at ease; the mind attains peace!

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Featured Pose: Triangle Pose

by Baxter

Triangle pose (Utthita Trikonasana) is one of the most commonly practiced standing poses, and for good reasons! This accessible pose can help build upper and lower body strength, can increase upper and lower body flexibility, and can improve your balance. It is also easy to modify for those, like me, who lack the flexibility to bring the bottom hand to the floor. And if you have trouble with balance, you can do the pose with your back to the wall. Overall this pose creates a wonderful feeling of openness. Without being overly demanding, this pose can be energizing when you’re lethargic or uplifting when you’re feeling blue.

Because the poses stretches your legs and hips, it is a good way to warm up for seated forward bends and supported inverted poses. And because the pose lengthens your spine and is a mild twist, it is a good way to warm up for seated twists.

I prescribe this pose for: 

• general stiffness and tightness in legs and shoulders
• general muscular weakness
• improving core strength 
• improving balance

Even though this pose is commonly taught, there are some minor controversies out there in the yoga-sphere about how to do it “correctly,” so today I’m going to share my favorite way to do the pose. I'll start with instructions for getting into the pose, being in the pose, and getting out of the pose, then list the cautions you should consider before doing the pose at the end.

Instructions:

Moving Into the Pose. Start in Mountain pose (Tadasana) facing the long edge of your mat. 

1. Step your feet wide apart, somewhere between 4 and 5 feet, depending on how tall you are and how long your legs are.

2. Spinning on your right heel pad, turn your right foot AND leg out 90 degrees toward the right short edge of your mat. You can usually tell if you have your leg turned out correctly if your kneecap points in the same direction as your middle toe. (Depending on your particular anatomy, there are exceptions to this alignment, but it works most of the time.)

3. Next, pivoting on the ball of your left foot’s big toe, kick your left heel back an inch or two towards the left short edge of your mat. This will turn your left foot in a bit toward the front foot. (I know there are other ways to adjust the back foot, but I find this way the most efficient and stable for your balance.) Check to make sure that after you adjust both feet both heels still line up with one another relative to the long axis of your mat.

Also, once your legs have taken on the new relationship, your hips should have naturally rotated a bit towards your front foot. This means your left hip point has rotated around towards your inner right leg and your hip points are no longer parallel to the long edge of your mat, as they were when you started. I like this new arrangement, as it is pretty healthy for the front hip joint and the left sacroiliac joint! Now, the chest may have gone along for the ride, but see if you can easily rotate the chest back to the left a little so it squares back up with the long edge of your mat (but don’t take the hips along!).

4. After you’ve established your feet, inhale your arms up and out to your sides, parallel with the floor. Then as you exhale, reach out over your front leg like you have a letter in your right hand that you need to pass over a chasm to your beloved! This will encourage the right side of your waist and chest to stay long, and not shorten and curl towards the ceiling. It will also cause a slight shift of your pelvis initially back to the left bit, and then the right side of the pelvis will tip down a bit.

5. At this point, engage your legs to stay straight and strong as you place your right hand on a chair seat, a block, or the floor, depending on your flexibility. Your propping should allow the right side of your body to stay relatively long and straight—you might need to set up in front of mirror to actually see this alignment.

Keeping your hips in their new location (don’t let them spin up!), allow your upper belly and chest to rotate around the axis of your spine toward the long edge of the mat and possibly a bit more skyward. Stop this action if your feet become ungrounded, if your knees start to bend, or if your pelvis starts to spin up.

For Very Flexible People: Hand on the Floor

For Less Flexible People: Hand on a Prop

6. You can line your arms up with each other if your lower hand is on the floor or a low block, but the higher your propping the more variation you might need for your top arm. I see a lot of students jamming their left shoulders or throwing their top arm way back behind their chest. Instead, consider aligning your top arm with the top edge of your shoulders, even if it angles down a bit from vertical.

I prefer to have students keep their heads and necks lining up with the rest of their spine, but there are a lot of other ways this is taught. I won’t go into this here, but for the healthy aging neck, this way is pretty neutral in the joints. You can try to rotate your head to look up or even down (I like to vary my head position while in a longer hold).

Being in the Pose. To keep you grounded and stable in the pose, allow a downward movement of energy from your hips to your feet. At the same time, allow an upward energy starting in your feet, which gains support in your pelvis and then travels up through spine to the crown of the head. At the same time, spread your arms away from your heart toward your hands.

How long to stay in Triangle depends on many factors, but I start with dynamically entering and exiting the pose with the breath a few times, and then stay in the pose statically for just a few breaths or for as long as 2-3 minutes. The longer you are in it, the more stretch takes place in some areas and the more strength is required in others! Take your time advancing how long you stay in.

Leaving the Pose. Keep the strong, grounded feeling in your legs, and then on an inhalation, as if someone has grabbed your top hand and is assisting you up, pivot your hips and torso back to vertical. Then exhale your arms to yours sides and bring your feet back to parallel with each other before repeating the pose on the second side.

Cautions: People with a tendency to hyperextend their front knee should be careful to not to jam the front knee into a locked position. Instead, shift some weight from your front heel to the ball of your front foot and micro-bend your front knee. For people with low back pain or sacroiliac dysfunction, Triangle pose sometimes can aggravate your condition. So if you are experiencing low back or sacroiliac pain in the pose, come out of the Triangle pose immediately. Finally, Nina learned from one of her female teachers, that if done too often, Triangle pose can be risky for women’s hips. So Nina recommends doing this pose only a few times a week, not every single day.

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The Worm & Fly & Science Problem

by Nina

Just a part of NY Times Diagram

As some of you may know by now, my husband, Dr. Brad Gibson, is a medical researcher who works at a research institute where the focus is on aging and age-related diseases. So I hear about a lot of studies that claim to have discovered this or that supplement or food that will slow aging or lengthen our life spans. We are often quite skeptical, especially when we learn about how the studies were done. Because it is expensive and time-consuming to test human beings (and sometimes unethical), these studies are often done on worms and flies. And concluding that the effects are going to be the same on human beings is rather a stretch. 

I was motivated to write about this today after seeing a wonderful graphic in the Sunday New York Times in the article A Handy Guide to Longer Living Through Science! (I'm pretty sure the title is ironic.) I actually started to laugh when I read that the study that proved green tea extends life was done on flies (and the one that proved that it won’t was done on mice). A lot of the other studies on supplements were done on worms.

There’s a reason for this. Worms and flies have very short life spans and also visible signs of aging. Yes, older worms get quite wrinkly, for example. So it’s easy to change something about their diet and then see an obvious result, either in a longer-than expected life span or some other physical change. But does that mean the same thing would happen in a human? 

Brad says:

"I suppose its no accident that the artist who created the graphic used a "mouse maze" of conflicting, supporting or just plain absurd experimental results that have been published in the last three years alone to illustrate the disarray of lifespan research. While we all would have our favorites, for example, "worms live longer in outer space" or "men decrease women's life spans" (sorry, dear), these studies point to several underlying assumptions (or misassumptions) about how scientists go about studying longevity or health span. For one, we use a number of model organisms, with worms, flies and mice being the favorites. This is obvious to anyone thinking about conducting such a study, as these animals live anywhere from a couple of weeks to 2-3 years at most. Two, as we compare results of similar regimens across these organisms, we get a lot of contradictory results—maybe not a huge surprise. However, the more troubling truth is that even when we use the same model organism, the results can be very different (Rapamycin slows aging in mice, Rapamycin doesn't slow mice aging). The reasons behind this are complex, but could be due to differences in mouse strain, or the lab they are raised in (different gut microbiome!). My read on this? Here goes: avoid gimmicky lifespan-increasing supplements and drugs and, of course, get plenty of exercise like yoga, as all studies seem to indicate a big beneficial effect in daily exercise." 

So have fun looking at this graphic summary of recent studies on aging. I myself was thrilled to see that the study that showed coffee extends life was done on humans! But wait—there was another study done on humans that shows coffee decreases life spans. Sigh. 

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Friday Q&A: Reflux (GERD) and Yoga

Q: I have a student who has reflux, has been to a doctor and has been told it is because the valve in her stomach is too small to keep acid from leaking out. After class she started feel the reflux and nausea. For her to safely and comfortably participate in a group class, what asanas should she avoid or modify? I'm guessing any inversions, along with being careful with twists that typically compress the digestive organs?

A: Reflux, or more accurately gastro-esophageal reflux disease (GERD), is actually quite common. The name itself gives you some information about what is going on: fluid from the stomach sack (gastro part) is “refluxing” or backwashing up into the esophagus, the tube that connects the mouth to the stomach sack. Food and fluid is supposed to be on a one-way trip, but with GERD, something is going on that allows the stomach fluids, which are quite acidic, to move up in the wrong direction back into the esophagus. The acidity of the stomach juices, essential to digesting and breaking down your food, can burn and inflame the lining of esophagus, which is not designed to handle stomach acids. Sometimes GERD is a result of the esophageal sphincter, the muscular valve that separates the esophagus from the stomach and normally allows one-way traffic, being too loose and relaxed (not tight). It then permits the backflow. In addition, the opening in the diaphragm, the main breathing muscle, that permits the esophagus to travel from the chest area into belly area, can sometimes be too large, which can allow for the stomach sack to slide up, or herniate, a bit into the chest area. This tends to make the esophageal sphincter less effective in its job, too. 

Someone with GERD can have a variety of symptoms, but by far the most common is heartburn. Your relationship to gravity can improve or worsen the symptoms of GERD. If you are standing upright, gravity works to keep the stomach acids down in the stomach and not up in the esophagus. However, if you are lying flat on your back or on your belly, or even worse, upside down, gravity will work against the normal flow and can contribute to worsening symptoms.

Therefore, the first thing I have done for my students with active GERD symptoms is to use blankets to create as slight ramp for them to lay on when we are doing floor work on the back or belly. This keeps just enough of a gravitational gradient that they can tolerate 15 minutes on their backs without stimulating symptoms. You can modify some partial inversions, such as Uttanasana, Prasarita Padottanasana, and Adho Muka Svanasana, to keep the chest and belly parallel with the floor or higher. For example, Half Downward-Facing Dog pose at the Wall is as a good alternative for full Downward-Facing Dog pose. 

You can do Legs up the Wall pose (Viparita Karani) with a ramp for the head, chest, and belly, and with no support under the hips. However, full inversions, such as Headstand and Shoulderstand, usually need to be put in mothballs until the practitioner’s GERD symptoms are treated adequately with the help of their doctor.

As for twists and side-bends that might increase the pressure inside the abdominal cavity and contribute the backflow into the esophagus, I have not seen this as a big deal for my students with GERD, although it is theoretically possible. My advice with these kinds of poses is to do them dynamically, for example, with a seated twist, entering on the inhalation and exiting on the exhalation, without holding it. Or, enter the twists or side bends gradually, shy of your maximum, and observe the effect on the GERD symptoms. If all is quiet, then consider going a bit deeper and observing again. You get the idea! 

And mentally focusing on your breath in certain ways can sometimes help to keep your body more relaxed and, theoretically, according to the yoga tradition, keep your body juices flowing downward. I encourage my students with GERD to visualize the energy of the body moving from head to pelvis on the exhalation. This would encourage the inward wind known as the apana vayu to move in its desired downward direction. Although this technique subtle, some students report it to be helpful.

The good news is that you can effectively and easily modify your own practice or that of your students with GERD so all of the great benefits of a well-rounded yoga practice are available without aggravating the GERD! For any of our readers out there who have GERD, what works and does not work for you? We’d love to hear!

—Baxter

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Life-Changer: Understanding Your Autonomic Nervous System

by Nina

An Examination at the Faculty of Medicine, Paris by Toulouse-Lautrec

We’re going to have an anatomy lesson today! I know, I know, you thought after you graduated, you wouldn’t need to be learning any more dry, technical stuff. But I swear to you this information is so useful that it could literally change your life (see 2 Steps to Take Charge of Your Stress or Anxiety). I know that because it has changed mine.

So, take a deep breath and take a look at the autonomic nervous system. Your autonomic nervous system is the part of your nervous system that regulates involuntary body functions, such as heartbeat, blood flow, breathing, and digestion. It’s called “autonomic” (hahaha, I just learned this) because the system works autonomously (automatically) without your conscious effort. (You don’t need to tell your heart to beat the same way you need to tell your front knee to bend to 90 degrees in Warrior 2 pose. Voluntary movements, such as knee bending, are controlled by your somatic nervous system.)

Although the functions of the autonomic nervous system are generally outside of voluntary control, they are not outside of your awareness, and they may be influenced by your state of mind. For example, although you can’t tell your heart to beat faster or more slowly, you can feel it beating. And when you’re calm, you’ll notice that your heart beats more slowly and when you’re afraid or angry, you’ll notice it beating more rapidly. 

The autonomic nervous system is divided into two parts that function in tandem with each other: the Sympathetic Nervous System and the Parasympathetic Nervous system. After the autonomic nervous system receives information about your body and the external environment, it responds by stimulating body processes, usually through the sympathetic division, or inhibiting them, usually through the parasympathetic division. (Some sources also include the gut nervous system, or the Enteric Nervous System, as a third, separate part of the ANS. But I’m not going to take a stand on that anatomical debate.)

About Your Sympathetic Nervous System

Your Sympathetic Nervous System (SNS) prepares your body for stressful or emergency situations. That’s why it is commonly called the Fight or Flight response. To prepare your body to deal with a challenging situation or an emergency, your SNS releases hormones—adrenaline and noradrenaline—to increase your heart rate, blood pressure, blood flow to the muscles, and widens (dilates) your airways to make breathing easier. It also causes your body to release stored energy and increases muscle strength is increased. After all, you might need to fight or run! Something that is mentioned less often, but that I’ve really noticed myself and which is really pertinent to yoga, is that your SNS causes your mind to race to increase your ability to assess your current situation and make important decisions. 

Importantly, while your SNS is stimulating certain processes, it is also slowing body processes that are not needed in emergencies, such as digestion and urination. Healing, including restoration and building of tissues, is also slowed down. So you can see why you don’t want to be in a state of stress 24/7! 

In addition, because your body is working extra hard during stressful periods, it can just wear you out faster, which is why heart disease is associated with stress. And having a racing mind all the time, well, that causes emotional problems, such as anxiety and depression, as well as insomnia because you can’t let go and just fall asleep. All this why chronic stress is so harmful to your physical as well as emotional health (see Chronic Stress: An Introduction and Stress, Your Health, and Yoga for more info about chronic stress.) 

We can’t and should not eliminate stress entirely from our lives. Sometimes in the modern world we do need to get out of danger, including mundane situations such as getting out of the way of an oncoming car, or more in more rare circumstances, such as protecting a family member from a threat. But our stress response also prepares us for some really good things in life, including running a race, traveling to a foreign country, having a creative brainstorm, falling in love with someone (that can be so scary, right?) or even —ahem—having an orgasm. 

But problems arise when we’re living in a state of chronic stress due to demands of ongoing challenges, such as our job, commuting, or family problems. In this case, understanding what the symptoms of stress are can help you identify your current state. Because when you realize you’re stressed out, you can and should try to reduce your stress levels. And the thing that most people don’t realize is that you can intentionally change your nervous system from being in the stress mode triggered by your SNS to a different state.

About Your Parasympathetic Nervous System

Your Parasympathetic Nervous System (PNS) controls your controls body process during ordinary situations, enabling you to recover from stressful periods. That’s why it is sometimes called the Rest and Digest response. The PNS reduces the levels of stress hormones in your body, slowing your heart rate, decreasing blood pressure, and so on. After all, these organs don’t need to work as hard now that the stressful situation has passed. And, now that you’re out of danger, your racing mind will also slow down and you’ll experience feelings of relaxation (the PNS is also sometimes called the Relaxation Response). 

Importantly, the PNS stimulates your digestive tract to process food and eliminate wastes, and using the energy from the processed food is to restore and build tissues. After all, you need to build yourself back up after being depleted by a period of stress. So you can see how vital it is to spend some time in this mode, in which you are resting, recovering, and acquiring energy. 

It’s important to understand that Rest and Digest state is quite different than sleep (see Conscious Relaxation vs. Sleep). That’s why sleeping—if you can sleep—doesn’t fix stress-related problems, such as heart disease, high blood pressure, headaches, digestive problems, and so on. And, as you may have noticed, sleep also doesn’t quiet your mind, either, as many stressed people spend their days feeling anxious or wake in the middle of the night with a racing mind. That has a profound effect on your emotional well-being. So the bottom line is that if you want to do your best to protect both your physical and emotional health, you need to make an effort to less time in stress mode and more time in conscious relaxation mode. 

But, if your autonomic nervous system is “automatic,” how exactly can you change it?

Influencing Your Autonomic Nervous System with Yoga

Remember, I said earlier that although the functions of your autonomic nervous system are generally outside of voluntary control, they may be influenced by your state of mind. I also said that the autonomic nervous system responds to information that it receives from both your body and the external environment. And this is why yoga is such a powerful solution for managing stress. 

Quieting Your Mind. Yes, it turns out the original purpose of yoga described in the Yoga Sutras as “the stilling of the changing states of the mind” is one of the keys. By meditating—which typically involves concentrating on a non-stressful sight, sound, or physical sensation—you can quiet your mind. This in turn switches your nervous system from stress mode to relaxation mode. (See The Relaxation Response by Dr. Herbert Bensen for complete information on this.) 

Working with Your Breath. It also turns out that pranayama—or breath control—allows you access your nervous system. By slowing your breath, as it would be in a state of relaxation, you can actually switch your nervous system from stress mode to relaxation mode. Baxter described how this works in his post How Your Breath Affects Your Nervous System.

Working with Your Environment. Finally, you can use your asana practice to create physical environment that will encourage your nervous system switch from stress mode to relaxation mode. Practicing relaxing or quieting yoga poses, such as restorative poses and supported forward bends, in a warm room, will send messages to your nervous system that you’re safe and comfortable. Yoga nidra and other forms of guided relaxation that you practice in Savasana will have the same effect. Inverted poses are a special case because these yoga poses take advantage of the mechanisms in your body that control your blood pressure to “trick” your nervous system into switching into relaxation mode (see Why You Should Love Your Baroreceptors). 

See The Relaxation Response and Yoga for more information about how you can use yoga to trigger the relaxation response. 

Well, it seems I’ve gone on much longer than I expected, but I felt I had some important things to explain. For those of you who didn’t already know this information about the nervous system, I hope you will find it as compelling as I do, and that it will empower you to deal more effectively with stressful situations and reduce your overall stress levels.

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2 Steps to Take Charge of Your Stress or Anxiety

by Nina

Enclosed Field with Rising Sun by van Gogh

Lately I’ve been trying to help several people who are suffering from stress and/or anxiety. Although these people are all quite different from each other—they range from a young woman with a new baby to man with newly diagnosed heart disease to an older man with chronic insomnia—I found myself saying the exact same things to each one of them. And since my advice was, in a way, very basic, I thought I’d write it up for the blog.

One of the things that motivated me to share this advice was that I was struck by something my friend said when talking over her daughter’s problems with her. “Well, I guess, anxiety just comes and goes.” My friend seemed to feel that her daughter was at the mercy of some emotion that took her over periodically and that there was nothing she could do to change that. But I feel that through a combination of educating yourself and making some lifestyle changes, you can empower yourself to deal more effectively with stressful situations and hopefully also reduce the levels of stress and/or anxiety that you are suffering from. 

And the advice I’ve been giving boils down to two simple steps.

1. Learn About Your Nervous System.

The first thing I always tell people I’m teaching to manage stress and anxiety is to read The Relaxation Response by Herbert Benson so they can learn about how their nervous system—specifically the autonomic nervous system—works. I recommend this book because although we have some information on the blog about the nervous system (see Chronic Stress: An Introduction and Stress, Your Health and Yoga), we don’t yet have a comprehensive overview of the nervous system. (I am going to write one tomorrow, though, because I’ve realized how important it is!) 

I feel strongly that educating yourself about your nervous system will help eliminate some of the mystery of what’s happening to you and empower you to make some important decisions. Knowing the symptoms of chronic stress, such as insomnia, digestive problems, headaches, high blood pressure and so on, will help you choose the right solutions (see below) for you and to take action before things get out of hand. And I also believe that knowing about how your nervous system works and understanding the difference between sleep and conscious relaxation (see Conscious Relaxation vs. Sleep) will motivate you to start practicing stress management. Otherwise, you might think—as one friend did—that exercise and sleep are all that is needed.

For example, I can always tell when I’m getting stressed out because I start sleeping poorly, lose my appetite (sometimes even feeling nauseated), and, because my mind is racing, I talk more than usual! If things get really bad, I start to feel a burning sensation in my chest. So rather than just waiting until things get even worse (I have been there—“going over the edge” I call it), I double down and focus my yoga practice on stress management (see Friday Q&A: Practicing to Manage Stress). I believe this has helped keep me emotionally healthy for almost 20 years now.

2. Find Ways to Manage Your Stress and Reduce Anxiety, and Practice Them.

Once you’ve learned about your nervous system and how important conscious relaxation is for your emotional as well as physical health, you should take the time to explore the possibilities yoga offers for helping you manage your stress and reduce your anxiety. We’ve been writing about the different ways that yoga can help you manage stress since the very earliest days of the blog. And throughout the years, we’ve continued to write about this. That’s because we feel that yoga includes such a wide range of possibilities that you’re sure to find something that works for you. Interestingly, the paper I wrote about in Self-Regulation, Psychological Health, and Yoga confirmed this very opinion!

But everyone needs to experiment to find what suits them best. For example, even though breath practices (see Friday Q&A: Breath Practices for Anxiety) are traditionally thought to be helpful for stress and anxiety, one person I’m working with found that breath practices I recommended tend to agitate him. Happily, however, I introduced him to supported forward bends, which he immediately found soothing. Another man I’ve been counseling does find breath work helpful, and he has used to it to relax while getting medical procedures that make him tense. He also really enjoys the guided relaxation tracks we have available on our site (see Audio Tracks). 

I myself love the breath practices and supported inversions (see All About Supported Inversions). But I never enjoy restorative yoga, unless I’m super exhausted, and I don’t like listening to an audio recording of any kind while I practice, which are two of Baxter’s favorite things. Hey, we’re all different, not only in our tastes but in the ways we get stressed out. See The Relaxation Response and Yoga for an overview of the different practices.

Finally, once you’ve identified the practices that work for you, you need to practice them regularly. This is crucial! Although some of the practices can provide quick, temporary relief, none are going to instantly re-balance your nervous system. After all, it probably took a while for your nervous system to become over-stressed, so it will take some time to return it to normal. But making the commitment to actively take care of yourself by practicing regularly is empowering—you are no longer at the complete mercy of outside forces—and that in itself is a huge step to take.

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Yoga May Slow Age-Related Changes in Healthy Adult Men

by Baxter

The Three Ages of Men by Giorgione

I am always excited to have good news to share with my male students about how yoga can improve their health, and when recently I learned about a study done in India that looked at yoga’s potential beneficial effects on aging for healthy men, I decided to check it out! I first read about the study “Age-related changes in cardiovascular system, autonomic functions, and levels of BDNF of healthy active males: role of yogic practice” on a web site. (I’ll get to what BDNF is in minute!) The web site discussed the findings of the study, but only positive information about the study presented and there was no mention of any limitations of how the study was done or whether its design would allow for us to draw comparisons to large groups of adults doing yoga. To me, this was a bit of a red flag. On the one hand, I was excited to see a study done that was checking blood chemicals, EKGs, and other signs of stress related to aging. Because I wanted to know more about the study, such as the actual number of participants and how long they were followed and if there was any long term follow up, I went the source, the actual paper itself. (Although you can’t access the paper yourself, you can find the abstract here.)

The first sentences of the abstract for the study gave me a good starting point on why the researchers were doing the paper. My translations of the scientific language into more accessible terms are in brackets.

“Aging is associated with decline in cardiovascular, autonomic function, and brain-derived neurotropic factor (BDNF). [this is what we know from present research on aging] Reports are scanty regarding whether yoga can improve age-related degenerative changes in healthy active men. [this is what we don’t know yet] This study is designed to appraise the role of yoga in improving age-related degenerative changes in cardio-metabolic risk profile, autonomic function, stress, and BDNF. [this is what scientists plan to look at] 

And I have to say that these researchers checked a lot of stuff in the participants to assess their goals—quite impressive! But how did they choose the men in the study? These were their criteria:

“Inclusion criteria included (1) normal healthy and physically active male; (2) absence of disease which could have contributed to obesity, hypertension, and neurological disorders; (3) not on medication; (4) no prior knowledge of yoga; and (5) smokers, alcoholics, and tobacco eaters (in India, where the study was done, they eat tobacco!) were excluded from study.” 

This seems reasonable: healthy, active men who have not done yoga before. However, one immediate problem was the small number of men in the study, only 60 in total. The authors looked at three groups of healthy men, 20 in each group, with age ranges of 20-29, 30-39, and 40-49. This is a concern because the smaller the numbers of participants, the less compelling the results of any study are. 

In studying this group, the scientists checked a variety of data related to aging, including blood tests for quite a number of markers, such as cortisol, and a brain substance called BDNF, or brain-derived neurotropic factor, which normally drops as we age. (BDNF is a key mediator of neuronal plasticity in adult, adult neurogenesis, and brain aging.) “Blood samples were collected in the morning after overnight fasting before and after 3 months yogic practice for biochemical estimation.” And the results are quite encouraging! Heart-, metabolic-, and neurologic-related aging changes were better in their study group.

So how much yoga and what kind of practices were these men doing? I was curious about what the yoga practice looked like: was it a simple beginner practice, and was it well rounded in poses, breath work and meditation?

According to the paper, “In addition to their routine activities, participants practiced one hour of yoga for 3 months in the morning with ambient temperature under supervision of qualified yoga instructor.” And here is what they did:

Table 2 Details of yogic module

Cleansing processes (2 min)

Kapalbhati (Rapid shallow breathing) 

Yogasanas (yogic postures): Total of 40 minutes

Suryanamaskar (sun salutation in 12 different postures, 1 round)

Padmasana 

Yogamudra

Matsayasana

Suptapavanmuktasana

Pavanmuktasana

Paschimottanasana

Vajrasana

Suptavajrasana

Gomukhasana

Sarvangasana

Halasana

Karnapedasana

Bhujangasana

Shavasana (relaxed supine posture)

Pranayama (breathing exercises): Total of 10 minutes

Bhastrika (forceful expulsion of breathing)

Anulom-vilom (alternative nostril breathing)

Bhramri (producing buzzing sound of bee with closed ear and lips)

Meditation: Total of 8 minutes

Omkar meditation (Om Chant)

Total session 60 minutes.

Although this protocol includes poses, breath work and meditation—a good balance—I’m concerned about the poses they practices, which are all symmetrical poses and are either forward bends or backbends, with no twists or side bends included. And many of the poses are intermediate ones, which someone unfamiliar with yoga might have trouble with, such as full Lotus, Shoulderstand and variations, and Reclined Thunderbolt pose, to name the most obvious. This could limit the applicability of this particular practice for the general population. 

To their credit, the authors do cite some of the limitations of the study, including the lack of control group (a control group is a similar number of healthy active men that did not do yoga and were evaluated with the same tests-this study does not have one): 

“The present study suffers from some limitations that need to be acknowledged and addressed. One of these is the relatively small sample size in each group. An additional limitation is that this study is a single-arm study without any separate control group.” 

And their final conclusion is also fairly accurate: 

“Based on the results of the present study, it may be concluded that the aging process has an active role on degenerative changes in cardio-metabolic risk factors, autonomic functions, and monoamines as well as levels of BDNF, which may revert back towards normal or near-normal levels through yogic practice in healthy active males. (bold is mine)” 

But the limitation that they did not mention is that we only know what the effect was at the end of three months of practice. We don’t know if these beneficial findings would be persistent at 6 or 12 months, let alone after 1, 2, or even 5 years. And would there be any persistent benefits if someone lapsed in their yoga practice or only did yoga two times a week? As with almost any yoga study I read these days, I am on the one hand encouraged by the positive results of this one for giving healthy men some compelling reasons to take up yoga, and on the other hand am reluctant to sound the horns of triumph until larger follow-up studies support these initial findings. And that, sadly, costs a lot of money to do! Any billionaires out there looking to support some good works in the world?

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