Ankylosing Spondylitis and Yoga (Not Yoga for Ankylosing Spondylitis)

by Shelly Prosko, PT, PYT, CPI

Sunflower in Bouquet

I recently had a physical therapist colleague ask me for some advice for some yoga poses that might help her client who has ankylosing spondylitis (AS). I explained that there are certainly some poses I would share with her that could potentially address some of the general commonalities of the symptoms of AS and how people with AS may present in similar ways, but I also explained I thought it was important for her and her client to understand that: 

1. Therapeutic yoga is so much more than prescribing poses for a particular dysfunction or special population.
2. The phrase "yoga for ankylosing spondylitis" (or any diagnosis) tends to suggest, in my opinion, that we are using a reductionist approach and falling into the trap of treating/addressing a diagnosis instead of a person who is a living, breathing, moving, thinking, feeling and reacting being, who is connected to and affected by the surrounding environment. Every being consists of complex systems and layers, each one influencing the other, including the nervous system, digestive system, musculoskeletal system, hormonal system, immune system, integumentary system, and emotional, social and spiritual layers, just to name a few.

That being said, there are certainly some common physiotherapy exercises and yoga methods that can be used for people looking to optimize spinal and rib mobility and alignment, maximize breath patterns, improve pain management, and/or calm the nervous system. But I suppose that would be a really long title for this article.  

I can appreciate how it's easier to simply say "Yoga For ( diagnosis )"; and I would assume we all understand that we're making generalizations that aren't to be used as prescriptions or individual therapies, but simply outlining some potentially valuable guidelines in order to help people. So, for the record, this article is not meant to be interpreted as “Yoga for Ankylosing Spondylitis.” I want to be clear that I strongly believe in “Yoga For the Individual Person” and his or her unique physical, mental, emotional, energetic, and spiritual states, which are constantly changing and responding.

Keeping this in mind, I'd like to share the response to my colleague's request. One of my yoga students, who happens to also have AS, was willing to demonstrate some physio and yoga techniques that I chose for this case. A short interview with him is also included at the end of the video about how yoga has helped him manage his AS symptoms. I hope you find the video valuable and perhaps even worth sharing with someone who you think may benefit from it: 

About Ankylosing Spondylitis

AS is a chronic inflammation of the joints of the spine and is considered to be an autoimmune disease. For reasons we do not know (although, there is speculation and theories presented) the body receives a trigger that tells it to “attack” itself. The body can potentially then go into repair mode, causing excess bone formation, which explains the fusion of joints that is sometimes seen in advanced AS.

Some of the symptoms and complications of AS are:

• pain experienced in the areas of SI joint, spine, hips, shoulders, knees, ankles 
• stiffness/reduced mobility of spine
• reduced chest/rib mobility or expansion, resulting in decreased efficient breathing patterns
• fatigue
• osteopenia/osteoporosis
• digestion problems (IBS)

Some of the intentions of PhysioYoga therapy in this case are to:

• reduce the chances or severity of secondary complications as above
• help improve management of symptoms as above
• maintain and optimize joint mobility and alignment
• optimize muscle health and function
• maximize efficient breathing patterns (which can help improve movement)
• improve self management of pain
• increase self-efficacy
• optimize feelings of joy, pleasure, and gratitude
• maximize functional capacity and quality of life

Certain yoga poses, movements and breathing methods can help address posture, alignment, mobility, and stability as well as potentially address the energetic layer (combat fatigue, improve sleep) or produce a calming effect on the nervous system, which can help with such problems as pain management. Mindfulness or meditation practices, such as awareness, visualization or other methods of focus, can also potentially help with pain management, change the pain experience, and perhaps even reduce the chance that the genes associated with inflammation are expressed. Ram's previous posts "Chronic Inflammation and Yoga" and "Meditation: Effects on Gene Expression" shed further light on these topics.

There is currently no formal test to actually diagnose AS. The Arthritis Society states that although most people who have AS carry the HLA-B27 gene, most people with the HLA-B27 gene do not get AS. So, just because you have the gene, it doesn't mean you will get AS. The Arthritis Society states, "in fact, only a very small number of people with this gene will ever develop AS."

If your physician suspects you have AS, it is a good idea to get a referral to a rheumatologist to help guide and manage your care. PhysioYoga can be used as a valuable and beneficial complementary therapy to your current medical treatment. I highly recommend following and continuing with your medical treatment plan, in addition to finding a physical therapist or health care professional in your area who is trained in integrating yoga therapy and nutritional therapy into his or her treatment sessions (online directories of practitioners across North America are here and here). Or perhaps a yoga therapist or teacher in your community can work together with your physical therapist and health care team for optimal success and safety.

With education, supportive treatment as needed, and guidance, people with AS can have active, meaningful, happy lives and relationships filled with vitality and longevity. 

Disclaimer: This article and video is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities.

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory  conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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Friday Q&A: Organ Prolapse and Intra-Abdominal Pressure

White Rose by Melina Meza

Today’s question was left as a comment on our post Organ Prolapse and Yoga, which was written by guest contributor Shelly Prosko. Rather than just leaving a short answer in the comments section, Shelly decided to write long, more thorough answer that we could share with all our readers. Thank you, Shelly!

Q: Thanks for the more nuanced understanding of this issue. Could you help me understand why uddiyana bandha increases IAP (intra-abdominal pressure)? My experience and theoretical understanding suggest that is would decrease pressure because a) the diaphragm is rising, thus relieving pressure on the abdomen, b) the pelvic floor will slightly life if it is relaxed during uddiyana, a sign of decreased pressure, c) the lungs are at less than atmospheric pressure, which should drop general fluid pressure in the torso. Am I missing something?

A: Thanks for your thoughtful and wonderful observation, insight, and question. It gives me an opportunity to more thoroughly explore this topic, and gives me a chance to better explain my perspective about re-evaluating the use of uddiyana bandha for prolapse.

You said, "the diaphragm is rising, thus relieving pressure on the abdomen". Well, yes, the diaphragm ascends on exhalation, but that doesn't automatically decrease intra-abdominal pressure (IAP). If abdominal muscles are engaging such that it increases pressure in the system (the abdominal cavity being the hydraulic part of the piston system), the intra-abdominal pressure may not necessarily be reduced at the end of exhalation, when the diaphragm is elevated.

You also said, "the pelvic floor will slightly life (lift) if it is relaxed during uddiyana, a sign of decreased pressure." I agree for the most part. If the pelvic floor and abdominals are truly relaxed and they draw upward/inwards during uddiyana bandha, one would assume the intra-abdominal pressure has reduced, resulting in a passive lifting effect of the abdominal and pelvic organs. However, it's a challenge to know if the pelvic floor is completely passively lifting or actually actively lifting without EMG, US, or internal manual palpation.

This is where I feel I need to clarify my perspective and explain my experience (personal and clinical) with uddiyana bandha. I am by no means a bandha expert. I understand there are different interpretations and teachings of uddiyana bandha, depending on lineage. Some of these may potentially increase intra-abdominal pressure, others may decrease intra-abdominal pressure, depending on how it is taught and understood.

Here is my translation and understanding of how uddiyana bandha is supposed to be performed (please feel free to add/clarify from your knowledge): After a full exhalation, breath is retained. The intercostals and perhaps even some accessory muscles of respiration are supposed to then be engaged to expand the rib cage, therefore increasing volume in the thoracic cavity which will create reduced intra-thoracic pressure. This, in turn, is supposed to pull up the respiratory diaphragm because of the vacuum created, which in turn is supposed to passively “suck” the abdominal organs up higher. One would assume the same for pelvic organs.

Although even though the “abdominal lock” is supposed to be a passive indrawing/lifting of the abdomen, I believe it is rarely taught or performed (in our western mainstream yoga culture) this way. Even the way we've translated it as the “abdominal lift” can be confusing. To me—and I know many others—this implies that the primary action is to “lift or pull in the abdomen” Instead, maybe we should call it “rib cage vacuum.”

But I've seen videos, books, and teachers give instructions to "pull the abdomen in." If that is the case, then potential is there to incorrectly use surrounding trunk/abdominal muscles to move the abdomen, increasing intra-abdominal pressure, which may be unfavorable for someone with prolapse. (I sure would love to do a study though!)

So, I do feel that people suffering from organ prolapse should re-evaluate their use of uddiyana bandha if they are performing it, particularly if they are performing this bandha regularly, thinking it should help, but they are getting worse (which I've witnessed). In retrospect, I would have re-worded my statement: "precaution with advanced yoga methods such as uddiyana bandha, as this could potentially increase intra-abdominal pressure if not performed correctly."

Finally, reader, I think you're onto something. There is actually a relatively new approach to treating reproductive organ prolapse that is gaining popularity in the pelvic health world called hypopressives. From photos/videos, it looks interestingly similar to uddiyana bandha. Research is still in its infancy, but perhaps there is actually some therapeutic value in uddiyana bandha for reproductive organ prolapse! 

Thanks for opening up this conversation and providing me with this opportunity to expand on this topic. Hope this helps clarify my article.

—Shelly

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory  conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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Organ Prolapse and Yoga

by Shelly Prosko

Iris in the Rain by Melina Meza

Recently the blog received a question from a yoga teacher asking about the role of yoga to both reduce the likelihood of prolapse in her students (most of whom are middle aged mothers of at least one child), and to serve as a therapy to those who have had the surgery and are looking to improve the situation. She also wanted to know if there any poses or actions that could potentially damage this area.

There is certainly a role that yoga can play in the management of reproductive organ prolapse, but there are also some poses, movements and breathing methods that could potentially exacerbate the condition. For our readers who may not be familiar with what a reproductive “organ prolapse” means, Wikipedia defines the term prolapse as “to fall out of place.” There can be different kinds of prolapses. The bladder, intestines, bowel, uterus or vaginal walls can “fall” or collapse downwards. A prolapse of one of these organs results when there is too much intra-abdominal pressure in the abdominal and pelvic cavities, causing a downward force that the pelvic floor muscles (PFM’s) and surrounding connective tissue are unable to support. The organs can even fall down through the vaginal opening.

It is beyond the scope of this post to outline the causes of a prolapse. But it is important to clarify the common misconception that prolapses are caused by weak PFM’s. Yes, if the PFM’s are weak, they won’t be able to hold or support the downward force of these organs, leading to an increase risk of a prolapse when the intra-abdominal pressure rises. However, there are other connective tissue structures like fascia and ligaments that help hold all of our pelvic organs in their respective space and place. You can imagine if these structures are damaged during childbirth, or if one of these organs is removed, as in a hysterectomy, that it will change the support system in the entire cavity. This is important to understand because it will dictate how you address the prolapse with yoga or other exercises.

To answer our reader's questions, we need to look at some yoga poses that might help improve support within and surrounding the pelvic and abdominal cavities without increasing an unfavourable amount of pressure, and then look at ones that might cause an unwanted increase in the intra-abdominal pressure, potentially worsening the prolapse.

Let’s first take a look at what poses or activities to avoid (or consider re-evaluating) in your practice:

1. Poses that tend to unfavourably increase the intra-abdominal pressure (IAP) are some of the intense core poses such as Boat (navasana), Four-Limbed Staff pose (Chaturanga Dandasana), Plank pose (on elbows or hands) or variations of these poses.
2. Uddiyana Bandha forcibly and considerably increases the IAP and can exacerbate prolapse.
3. Depending on the severity of the prolapse, forward bending poses with the legs abducted (wide apart), may induce an increased downward pressure in the pelvic cavity that the PFM’s cannot support, such as Garland pose (Malasana), Wide-Legged Forward bend (Prasarita Padottanasana), Extended Child’s Pose (big toes are touching, heels and knees are wide apart, and arms extending forward).
4. Power or flow yoga transitions where there is jumping. Repeated jumping consistently increases the downward force. 
5. Breath Holding. If ANY yoga pose is too challenging for you or causes you to strain and hold your breath, then this can cause an increase in the intra-abdominal pressure, worsening your prolapse. Proper breathing during any yoga practice or other activity is always important for pelvic health and overall health of many systems of your body!
6. Avoid Kapal Bhati Pranayama (vigorous abdominal contractions during breath method).
7. Avoid activities such as heavy lifting or “pushing” (as in constipation). Lifestyle choices (forcing yourself to take several trips to unload groceries) and nutritional changes (increase bowel motility and softening) may be helpful.

Here are some poses or activities that may help manage or reduce symptoms in your practice:

1. Slightly elevate hips during Legs up the Wall pose (Viparita Karani), Supported Bridge pose (Setu Bandha Sarvangasana), Reclined Cobbler’s pose (Supta Baddha Konasana), Supported Shoulderstand (Salamba Sarvangasana).
2. Focus on awareness of the pelvic diaphragmatic breath or Reverse Kegel. Many people experiencing a prolapse assume that their PFM’s are loose and need to be tightened.  However, Jocelyn Unger, a PT pelvic health specialist at the University of Arizona Health Network agrees that the majority of women she treats that have weak and ineffective PFM’s, but also that they demonstrate tight PFM’s.  For this reason, she, along with many of the leading pelvic health specialists, recommend focusing first and foremost on the RELAXATION and release of the PFM’s before learning to engage and activate. See Urinary Incontinence for info on the pelvic diaphragmatic breath method or Reverse Kegel.
3. Breathe. It is important to ensure you are breathing effectively and not holding your breath in all your yoga poses, and in all your activities of daily living. Breath holding can increase strain and pressure against the pelvic floor. However, you must be even more mindful of effective breathing strategies in standing poses; because the force of gravity pulls downwards, the position of standing may be a somewhat precarious position if the prolapse is moderate to severe.
4. Mountain pose (Tadasana) and modified Powerful pose pose (Utkatasana) with a block between the thighs, ensuring proper postural alignment.  Alignment of the spine and pelvis can influence the position of the abdominal and pelvic organs and also influence the effectiveness of the PFM’s ability to contract. Ensuring you have a natural low back curve with a neutral pelvic alignment in your standing poses is important. An assessment from your physical therapist can help you determine where your optimal lumbo-pelvic position should be. Modify the Powerful pose simply by not squatting down as far so that there is no extra unwanted downward pressure.
5. Pranayama (breathing methods) that are meant to calm the nervous system would be beneficial for addressing anxiety that sometimes causes you to hold tension in the pelvic area. Nadi Shodana (alternate nostril breathing), Abdominal-Diaphragmatic breathing (Belly Breath) and Bee’s breath (Bhramari) may be useful.

Once you have practiced pelvic diaphragmatic breath awareness and learned to release the PFM’s, then you may be ready to start a gentle engagement of the pelvic floor muscles AS YOU EXHALE. Lie on your back with your knees bent and feet flat on the mat, or sit upright in a comfortable position. As you inhale, allow your belly to naturally move out. As you exhale, very gently draw your lower belly inwards, keeping your spine and pelvis neutral.  Inhale and relax, allowing your belly to soften. During the next exhalation, you can try to add a gentle lifting sensation of the pelvic floor. This is an extremely subtle movement, but is the beginning of learning how to incorporate gentle core activation movements, which may be part of your overall prolapse yoga program. I recommend seeking a health care professional who can help you accurately activate these muscles before you start engaging them in your yoga practice, as research shows they often are not engaged properly in group settings.

It is important to understand that these poses do not treat a prolapse. There are a variety of causes, severities and treatment options for different prolapses, so it is wise to follow advice from your health care practitioner as to which treatment approach is best suited for you and your specific case.

Finally, our reader asked about using yoga to prevent organ prolapse for her students. It is inaccurate for me to say these exercises will help prevent a prolapse, because there are truly so many different factors that contribute to prolapse, some of which we can’t control. Therefore, it would be almost impossible to pinpoint the cause that may be unique to each of your students. However, if you take into consideration some of the above tips and recommendations, this may help reduce some of the risk factors. I would strongly encourage ALL women to visit a Physical Therapist who specializes in pelvic health PT at any stage in life, so their alignment and pelvic floor health can be individually assessed, and a home program unique to their needs can be implemented.

A visit to your pelvic health specialist does not need to be only when a dysfunction arises! As a yoga teacher, it would be helpful if you could find a pelvic health PT in your area that you can team up with to discuss individual home yoga programs for your students with these prolapse concerns. The PT could assess each woman and then communicate with you what areas need to be addressed for optimal pelvic health. This would be a great preventative and health creation approach. Pelvic health PT’s are found in these online directories across Canada and the USA. 

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches.

Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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Treatment of Incontinence: The Physio-Yoga Therapy Approach

by Shelly Prosko

Garland Pose (Malasana)

In my last post for Yoga for Healthy Aging To Leak or Not to Leak: Urinary Incontinence, I explored the main types of incontinence: stress, urge and mixed. I emphasized that when addressing any pelvic floor dysfunctions, including incontinence, it is essential to first cultivate a sense of awareness of the pelvic floor and learn to release the pelvic floor muscles (PFM’s) before engaging or strengthening even begins. You can do this by performing some of the yoga postures I shared in conjunction with abdomino-diaphragmatic breathing as well as the Toilet Meditation in the last post. I cannot stress enough how important it is to first learn this awareness and release, regardless of your issue.

Please remember that treating incontinence is not just about doing Kegels by contracting or strengthening the PFM’s, even if your dysfunction is due to weakness. Just like any other muscle in our body, PFM’s need to be both flexible and functional.Yes, they need to be strong when we need them to be. However, alignment, flexibility, strength, control, timing and awareness are all important factors for creating and sustaining a healthy pelvic floor. In fact, it is common that weak PFM’s are also tight (Just because a muscle is tight doesn’t mean it is strong!)

It is my intention in this post to share a few more yoga poses and physical therapy exercises you can use to address incontinence issues. Keep in mind that these poses are not specific to a particular individual’s needs, but are generic in addressing some of the overall body alignment, tightness, and weakness issues surrounding common pelvic floor dysfunctions.

It is very important that you first find out which type of incontinence you have from a pelvic health specialist and that you have one on one instruction on how to perform a PFM contraction, if that is indicated as part of your overall treatment plan. Some of these poses and exercises could potentially make your incontinence or pelvic health dysfunction worse. I highly recommend that you find a Physical Therapist (PT) in your area that specializes in pelvic health (see Canada or USA).

Once you have an assessment and know which type of incontinence you have and what specifically needs to be addressed in the surrounding areas of your body that may be influencing your incontinence, then you can have your PT communicate these needs to your yoga teacher. Together you can choose some yoga asanas, awareness meditation, and breathing methods that are safe and effective for you and your pelvic dysfunction.  If you are fortunate to find a pelvic PT that is also a Yoga Therapist, then that is icing on the cake! This is an example of how combining both physical therapy and yoga approaches can help optimize the success of your treatment.

Here are a few yoga poses and Physical Therapy exercises that may be beneficial for improving hip and lumbo-pelvic stability, mobility and alignment (which can all play a role in stress or mixed incontinence).

Yoga Poses

• Goddess pose/Fierce Angle pose (Utkata Konasana)
• Powerful pose/ Chair pose (Utkatasana), with a block between your thighs
• Bridge pose (Setubanda Sarvagasana), with a block between your thighs
• One-Legged Bridge pose (lift one leg off mat, keeping pelvis level and neutral)
• Cat/Cow pose (Bitilasana)
• Half Moon pose (Arda Chandrasana), Tree pose (Vksanana), Warrior III pose (Virabradrasha III), Triangle pose (Trikonasana)
• Crescent Lunge (Alanasa)

Physical Therapy Exercises

• Clamshell (lying on your side with the soles of feet together, open your knees like a clamshell)
• Straight Leg Circles (lying on your side)
• Four-point (on your hands and knees) arm, leg lifts & fire hydrant (on your hands and knees, performing lower extremity abduction as a dog would lift its leg and urinate keeping lumbo-pelvic alignment neutral)

Here are a few yoga poses that may be beneficial for addressing hip and pelvic floor tightness (which can be present in urge, stress or mixed incontinence): 

• Happy Baby pose (Ananda Balasana) and Half Happy Baby pose
• Cow-Face Pose (Gomukhasana)
• Pigeon pose preparation (Eka Pada Rajakapotasana), bending forward
• Cobbler’s pose (Baddha Konasana), Reclined Cobbler’s pose (Supta Baddha Konasana)
• Extended Child’s pose (Balsana)
• Dropped Knee Lunge/Hip Flexor Stretch
• Garland pose (Malasana)
• Eye of the Needle pose (Sucirandhrasana), lying on your back or seated with your back to the wall, as you cross one ankle over the opposite thigh, and bring your thigh to chest.

For any in the second set of poses, I have my clients observe the natural rhythm and motion of the pelvic and respiratory diaphragms as they relate to inhalation and exhalation. This is where I focus on awareness meditation of the pelvic floor. As you inhale, both diaphragms naturally descend. As you exhale, they ascend back to their resting positions. With supervision and proper instruction, you can attempt to activate your PFM’s as you exhale (in keeping with the natural rhythm of the diaphragms).  I have heard this natural motion be referred to as the “Reverse Kegel” because the pelvic floor/diaphragm actually goes downwards as you inhale, not upward. Try to simply watch and observe the natural rhythm. If you feel yours is opposite, there is a strong chance that you are breathing inefficiently or holding when and where you don’t need to. This could be contributing to any issues you may be experiencing in a variety of areas of your body!

Here's a video I made to demonstrate this form of breathing (see youtube). In it, I demonstrate the Pelvic Diaphragmatic Breath aka Pelvic Diaphragmatic Rhythm or Reverse Kegel. I perform it in Garland pose (modified), Extended Child’s pose, and Reclined Cobbler’s pose. I hope you find it useful.

Lastly, I want to discuss Mula Bandha. As I previously mentioned in my last post, I am far from a bandha expert. But the way I teach Mula Bandha does not necessarily equate to a PFM contraction. And many yoga teachers agree it is an “awareness” and an energetic sensation of the pelvic diaphragm—not a squeeze or contraction. This is because we do know that more holding, tightness, and tension can potentially do you more harm than good. This overuse and holding can fatigue the PFM’s, so that when it is time for them to perform their duties and actually contract to stop the flow of urine, they fail. Additionally, this holding can create or exacerbate a variety of pelvic pain disorders.

If Mula Bandha isn't something you are familiar with or use in your current practice, do not worry about it. If you do use it, perhaps seek guidance from your health care professional to ensure it is appropriate to use for your specific condition, and that you aren't doing anything to jeopardize the health or function of your PFM's. I simply recommend exploring the pelvic floor (whether you label it as “Mula Bandha” or not) as a mindful observation of the natural rhythm of your pelvic diaphragm as you breathe, in a variety of positions or yoga poses. Explore what releasing the PFM’s means to you, again, in a variety of yoga poses.

Perform your Toilet Meditation (see Yoga for Healthy Aging To Leak or Not to Leak: Urinary Incontinence). Then, after you have a sense of awareness and what it means to release, you can start to explore what it means to engage your PFM’s. Explore engaging PFM’s as you exhale. Current research supports that PFM strengthening is not performed correctly when taught in group settings. It is therefore recommended to receive one-on-one instruction and supervision from your health care professional when you are ready to start the PFM strengthening part of your pelvic rehab program, and if it is indeed indicated in your specific case!

Unfortunately, I have heard some yoga teachers give the instruction: activate Mula Bandha as you take a deep breath in. This type of rhythm can contribute to an unhealthy paradoxical breath pattern (which is an entirely other topic to discuss!), which can result in a plethora of states of “dis-ease” in our bodies. As explained above, the natural rhythm of our pelvic and respiratory diaphragms is to descend as we inhale, not the opposite. I really like Leslie Kaminoff’s perspective. See his videos Bandhas in a Modern Practice: A Historical Perspective  and Juggling Effort and Release: Where do Bandhas Fit in?.

“If everything we’re trying to accomplish in our practice is somehow fundamentally linked to this simple process of inhale/exhale, then we’re usually fine.” — Leslie Kaminoff

This resonates with me because I have seen this “trying too hard to do too much” attitude of “more is better” in my clients and my own personal practice. As a result, thinking about adding yet another process, like Mula Bandha can create more obstacles and tension. I’m not saying to ignore it; in fact, I’m saying the opposite. I want you to be more aware of the pelvic floor than you ever have, but without the expectation of trying to contract it or do something to “fix it” or “make it better.” 

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches.

Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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Sudden Acute Traumatic Injury

by Shelly Prosko

“Hey I did it! Look everyone, I’m doing it!” was what I remember thinking when I was Double Dutch skipping at our recent family Christmas function.  I was feeling confident, smiling and showing off my superb skills at age 41. Even though I hadn’t skipped in 25 years, I could still keep up with the kids because I take such good care of myself—I’m fit, agile, do yoga for healthy aging, meditate, eat healthy, create joy, educate and inspire others to do the same. Life is good. I’m so perfectly healthy. Then I remember a sudden intense “hit” to the back of my lower calf at my Achilles tendon that accompanied a loud pop. I went down in excruciating pain—and shock. I was looking around to see what steel object had hit me at such supersonic speed. But I couldn’t find anything. My cousin said, “Nothing hit you, you just went down.” It was then that I knew from experience as a physical therapist that I had completely ruptured my Achilles tendon. This is an example of an acute unexpected orthopedic traumatic injury. I have treated several of these types of injuries over my career, but when you are the patient, it’s a completely different ball game.

Shari’s post on Acute Orthopedic Injuries defines what an acute orthopedic injury is and how it is managed. Today I’d like to discuss the process that you may go through after sustaining an unexpected traumatic injury and how yoga can help you through the process. This is based on my experience in treating these injuries over the past 15 years in an outpatient orthopedic setting, as well as my recent personal experience.

Immediately after my injury, I was in shock for about an hour after. I was also in denial, and not thinking clearly. I didn’t even go to ER that night. Intellectually I “knew” the treatment protocol and prognosis, but for some reason, I wasn’t relating it to my own situation. This makes me realize how important it is to have support and allow people to help you when you are going through trauma. I wasn’t in a balanced mental or emotional state, and I certainly wasn’t equipped to be making important decisions. However, it’s in this state, that we are asked to make a decision: Do you want to treat this surgically or take the conservative, non-operative approach?

The benefits of my regular yoga and meditation practice were becoming evident as I embraced the truth of the situation, surrendered and became completely present in the moment. The combination of increased mental clarity and wonderful support from family and friends led me to finally go to the ER the next morning.

I was informed that the recent literature shows that there is not much difference in the long-term outcome between surgical vs. non-operative approaches and that they don’t commonly do surgical repairs to the Achilles anymore. I would be placed in a plaster cast for two weeks, then transfer to a boot cast for six to eight more weeks after that. The surgeon said, “Okay?” I replied “Okay.” Then he left the room and started working on making my cast. I don’t remember asking many questions. Typically, I would ask many! But I was not my usual self. I was still overwhelmed with emotion: fear, anger, guilt and sense of loss. Everything was just happening so fast. I remember hearing similar stories from patients. I would guess many people go through this type of experience.

Over the next week, the question lingered: Should I get surgery or not? There are so many factors to consider when you are deciding whether or not to undergo surgery. For the first several days, I was using vijnanamaya kosha (intellect, wisdom) to aid my decision: researching evidence-based results online, reviewing my own anecdotal evidence from clinical experience, analyzing other PT’s opinions, having discussions with family members and spending time in self reflection. These methods certainly played a huge role in my decision. We must use our mind as a tool to process all the information, so that we make an “informed” decision. But as many of you know, when you have a difficult decision to make, and you’ve analyzed it over and over again from all angles, sometimes your mind is no longer of service to you. You just need to make the decision, and, as Shari said, “make the right choice for me.”

I want to share the role that meditation can play in making decisions. Simply observing all thoughts and emotions without trying to “fix” or “decide” for a few minutes each day helped me in my decision.  I found that connecting to that space where my true self lies—without expecting or looking for an answer to my dilemma—was very beneficial to creating a clear mind. Often times the answer comes effortlessly after this (although it’s not wise going into the meditation expecting the answer because then you have defeated the intention of the meditation practice in the first place).

A yoga therapist/PT friend recommended that I try accessing pranamayakosha (energetic body) to help with the decision, an approach you might want to try for yourself. He recommended that I visualize each scenario in detail, and simply watch how my breath responds. I also brought awareness to how each scenario physically felt in my body. It was astounding to see the difference between the two scenarios. In the end, I opted to stay with the conservative approach to treatment and I can say that I finally feel at peace with my decision.

But it’s not over. I was told that rehab would not START for another eight weeks. As a physical therapist and yoga therapist, I intuitively know that there are SO many other areas and issues that can be addressed immediately post injury, even if we cannot touch or move the injured body part.
Allow me to briefly outline how I’ve been able to immediately use yoga for rehabilitation of this acute traumatic orthopedic injury. Keep in mind that yoga is not simply asana practice. “Yoga” means to “yoke” or unite body, mind, breath and spirit. In yoga, we can address all five kosha layers to optimize healing:

Annamayakosha (physical body):

• Asana practice involving non-injured body parts will help me maintain overall physical conditioning, to prevent overuse injuries of areas being overworked due to abnormal mobility patterns and to improve overall feelings of well-being. My practice includes Cat/Cow pose, Thread the Needle hip opener, One-Legged Downward-Facing Dog pose, One-Legged Plank pose, Happy Baby pose, and modified standing poses with a chair and bolster (Warrior II, Extended Side Angle pose Resolved Extended Side Angle pose, Reverse Warrior pose, Eagle pose arms, Cobra pose, Supported Side Twist with bolster, and Legs Up the Wall pose. Here’s the first in a series of videos that show my practice (you can find the rest here on my youtube channel):

Vijnanamayakosha (intellectual/wisdom):

• Injury Education. I researched recent literature about my injury. 
• Meditation methods for pain and anxiety control. I’m using a variety of focused mantra meditations and mental/visual imagery via a body scan.

Pranamayakosha (energetic):

• Breathing methods to address pain and/or anxiety. I’m using belly breath, nadi shodana, and bee’s breath.
• Focused meditation on breath.  Simply watching/observing without trying to change pattern has been one of my most powerful tools for finding peace during times of intense crying and frustration.

Manomayakosha (mental/emotional):

• Resources and support for grief/loss (injuries resulting in any form of loss are traumatic regardless of ‘severity’). What is working for me includes conversations with trusted family and friends and readings from “Untethered Soul,” including this interpretation of Yoga Sutra 2.16: “Painful effects that are likely to occur should be anticipated and avoided.” (See here for more info.) 
• Meditation. I’m practicing observing and watching emotions without trying to change them, but knowing they are “not me.”

Anandamayakosha (spiritual):

• For me, spirituality is connection to that space within that is true self, therefore connecting us to nature and all living beings. Injuries commonly cause a reduction of participation in normal social activities, resulting in feelings of isolation, loss and even depression. Connecting to ourselves, to others and to nature (even a daily brief outdoor meditation) can help us continue to feel this deep connection to spirit, which I believe is essential in any healing process.

I will continue to address all five koshas over the next eight weeks of waiting for “official rehab” to begin. Of course, this outline is unique to my current situation and it obviously does not serve as medical advice for your injury. However, I hope this sheds some light on how you could use yoga to help promote your healing in similar ways, even after an acute unexpected orthopedic injury!

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Licensed Physical Therapist, Professional Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, yoga classes, private PhysioYoga sessions, lecturing at University and College programs, instructing at Yoga Teacher Trainings and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more details and information.

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