Stroke: Yoga for Rehabilitation

by Ram

Sunflowers by Melina Meza

Your brain cannot function if it is deprived of oxygen even for a very short time. Without oxygen, brain cells start to die. A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is either ruptures (hemorrhage) or is blocked by a clot (ischemia). In either situation, portions of the brain do not receive much needed blood and oxygen, as a result of which the brain cells die (see Balance, Strokes, and Brain Health). If brain cells die or are damaged because of a stroke, symptoms occur in the parts of the body that this region of the brain controls. 

Symptoms of a stroke include but not limited to: failure to move one or more limbs on one side of the body, inability to understand conversation, difficulty formulating speech, numbness, postural instability and imbalance, and vision impairment. A stroke can cause severe brain damage, long-term disability, or even death. Prevention is the best remedy for people who are at risk. Interventions include a regular wholesome diet, physical exercise, avoiding smoking, and limiting alcohol use, among others.

Victims of stroke have to undergo several weeks or months of rehabilitation in order to return to normal daily living. The rehab process helps the victim restore and relearn lost skills arising from the brain damage. If the stroke victim is experiencing any severe disabilities, the rehabilitation process teaches them alternate ways to perform those tasks and to overcome those disabilities. According to most experts, a successful rehabilitation program is one that is carefully directed and well-focused, with emphasis on repetitive practice—all of which enables victims to regain their lost motor function and skill sets. Skills include ability to walk, use of hand movements, communication, speaking, bathing and dressing, among others. Victims also engage in physical exercises, including passive or active range of motion exercises to strengthen their limbs. Patients may progress from sitting up and being moved to standing, balancing, and walking, with or without assistance. Rehabilitation is an ongoing process until the victims are able to successfully carry out basic activities of daily living independently. Depending on the extent of stroke, this may take months or even several years. 

Stroke is a leading cause of disability in the United States. While 40% of stroke patients suffer from moderate functional impairment, 15% to 30% of victims are left with severe disability. Effective rehabilitation interventions initiated early on can boost the recovery process and lessen functional disability. Approximately, seven million people in the US suffer from the chronic effects of stroke and only 14% of these victims recover completely after one year of rehabilitation programs. Thus, there is a greater need to improve functional outcomes following stroke. Stroke victims need to engage in physical activities despite being very fearful. Can yoga be used in rehabilitation programs and be helpful to stroke victims in their recovery process? 

Apparently, yes! A recent study Yoga leads to multiple physical improvements after stroke, a pilot study. showed that yoga not only improves physical function, it also helps patients to overcome the fear of physical activity. The goal of the study was to assess the changes in physical function in people with chronic stroke after an eight-week yoga therapy program. The parameters measured included pain, strength, endurance and range of motion, as these are most affected after a stroke. A total of 47 people were enrolled in the study. All participants were older than 18 years of age, had completed all stroke inpatient and outpatient rehabilitation, and were able to stand without a device and follow directions. There were two groups in the study: the yoga group and the control group. The control group was actually a wait-listed group (n=10 people), who were offered yoga after completion of all assessments. The authors fail to mention if the people in the control group were on any medication or if they were doing some other physical activities.

Patients in the yoga group participated in group yoga therapy sessions with 10 people per group. Each yoga session was one hour long, and participants engaged in two yoga sessions per week for a total of eight weeks. The yoga session, which was taught by a certified yoga therapist, included sitting, standing, and supine hatha yoga poses and ended with meditation and relaxation. At the end of the eight-week period, the researchers noted that the yoga therapy group showed significant improvement in many aspects of physical function. Nearly all of the people in the yoga group described their pain levels as significantly reduced. Endurance had also significantly improved in the yoga group as they were able to walk farther in a six-minute walk test compared to the non-yoga group. Bilateral neck and hamstring range of motion and upper extremity strength significantly improved in the yoga group compared to non-yoga control group.

Thus, the research study clearly demonstrated that in just two sessions/week for an eight-week period (16 yoga classes) there were radical changes in several physical functional parameters in stroke victims, including pain, range of motion, endurance and strength, all of which correlated with improved functional outcomes. The researchers also speculate that in addition to improvements in the physical body, yoga may have also helped patients to develop more awareness that in turn led to a better recovery. Despite some limitations to this study (small sample size, an non-blinded trial, involvement of the main researcher with the yoga therapy group), yoga definitely appeared to have a positive impact on stroke victims by not only improving physical function, but also the quality of life. I guess you will agree with me that we cannot find a better, cheaper, more effective and environmentally friendly therapy for recovery after a stroke.

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Balance, Strokes, and Brain Health

by Ram

Before reading this article, please attempt this exercise: 

1. Start with bare feet. 
2. Grab a pair of socks. 
3. From standing, bend one knee and raise that leg out in front of you, keeping your knee bent. From here, try to put a sock on your raised foot while maintaining your balance. 
4. Repeat the same procedure on the other leg.

If you successfully managed to put on both socks without losing your balance, congratulate yourself and do this exercise daily. However, if you struggled with your balance, you need to think about strategies to strengthen your balance centers in the brain as this may affect your quality of life and lifespan. According to a recent study, people who cannot stay balanced on one leg for longer than 20 seconds need to consult with their doctor as this may strongly correlate with the presence of tiny micro-bleeds in the brain that may be a harbinger for an impending stroke. The micro-bleeds can happen even when you’re otherwise feeling healthy, and if this is not stopped or controlled, it can serve as a greatest risk factor for future severe strokes.

To understand this concept better, let us take a closer look at the anatomy of the brain and the balance centers. There are three main components of the brain: the cerebrum, the cerebellum, and the brain stem. Each component has a distinct function. The cerebrum is composed of two layers. The thick outer-most layer known as the cortex aka gray matter contains the centers of cognition, personality, and coordination of complicated movements. The inner white matter is a rich network of neuronal fibers that help the brain regions to communicate with each other. The entire cerebrum is divided into right and left hemispheres, with the left hemisphere controlling the majority of functions on the right side of the body and the right hemisphere controlling most of functions on the left side of the body. Any injury to the left hemisphere produces motor deficits on the right side, and vice versa. A stroke in the left or right hemisphere of the cerebrum can lead to impairment of perception and orientation, resulting in improper balance.

The brain stem is a region of the brain that connects the cerebral structures to the spinal cord. The brain stem is responsible for a variety of autonomic functions including respiration, heart rate, blood pressure, wakefulness and arousal among others. Some common effects of a stroke in the brain stem include problems with balance, coordination, weakness or paralysis among others.

The cerebellum, the second largest area, lies beneath and behind the cerebrum towards the back of the skull. It receives sensory information from the body through the spinal cord and helps to coordinate muscle action, fine movement, coordination, and balance. The effects of strokes in the cerebellar area result in improper balance, difficulty maintaining balance, inability to walk and problems with coordination and movement.

Unlike other regions of the body, the brain cannot function if it is deprived of oxygen even for a very short time. Without oxygen, brain cells start to die. A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is either blocked by a clot or if it ruptures. In either situation, portions of the brain do not receive the much needed blood and oxygen as a result of which the brain cells die. If brain cells die or are damaged because of a stroke, symptoms occur in the parts of the body that this region of the brain controls. A stroke can cause severe brain damage, long-term disability, or even death. A class of strokes called “whispering strokes” aka “silent" strokes do not result in any gross symptoms to raise concerns among victims. These strokes are often associated with tiny micro-bleeds (small blood vessel tear). Whispering/silent strokes that occur very frequently can serve as a greatest risk factor for future severe strokes and ultimately diminish patients' physical and mental functioning. But how does one recognize the presence of micro-bleeds if it does not trigger visible symptoms?

In a recent study Association of postural instability with asymptomatic cerebrovascular damage and cognitive decline: the Japan shimanami health promoting program study. published in the journal STROKE, a team of Japanese researchers noted that the inability to balance on one leg for 20 seconds or longer could be linked to whispering strokes due to micro-bleeds. The researchers recruited 841 women and 546 men who had an average age of 67. The participants were required to stand on one leg for up to one minute with both eyes open. They were asked to do this twice, and the best of the two timings was recorded. Then, the brain of each participant was examined using magnetic resonance imaging to check for any micro-bleeds. The participants were also asked to fill out computer-based questionnaires to assess any cognitive impairment. Using the brain MRI scans the researchers found that all those subjects who had micro-bleeds in their brains were also those that were unable to balance on one leg for longer than 20 seconds. Nearly 35% of those with a couple or more of micro-bleed lesions had trouble balancing, though they did not manifest any other gross symptoms. Moreover, balance problems were also associated with reduced thinking and memory skills.

According to the authors, small blood vessel damages in the brain coupled with reduced cognitive function in otherwise healthy people with no clinical symptoms can simply be observed by their ability to balance on one leg. Individuals who show poor balance on one leg will need serious attention, since this may indicate that small strokes or tiny bleeds have already occurred, which further means the risk for more serious strokes is high. One-leg standing time may thus serve as a simple, inexpensive, low-tech but powerful method to screen people for small cerebral vessel damage who are at risk for further strokes and thereby provide indication of their overall brain health.

So the question you must be asking is: what has this got to do with yoga? Firstly, how about taking preventative measures instead of waiting for the stroke (whether a silent/whispering or a major) to happen? How about strengthening the brain, the nerves, the cognitive skills and furthermore the balance centers of the brain? Remember all my rants The Power of Mental Exercise about the brain being plastic and how a combination of Yoga, meditation and pranayama helps to strengthen the neural connections that in turn improve memory, balance, speed and focus? We also need to be mindful of our relative balance abilities as we practice these modalities and look for ways to build, improve and maintain our balance.

In your regular yoga practice, you could bring in several one-legged balance poses, including, but not limited to, Vrkshasana (Tree Pose), Virabhadrasana 3 (Warrior 3), Utthita Hasta Padangusthasana (Extended Hand to Toe Pose), Urdhva Prasarita Eka Padasana (Standing Split), and Natarajasana (Lord of the Dance Pose). Baxter recently wrote about some of these balance poses in his post Featured Sequence: Challenging Balance Practice. The more complicated the one-legged poses, the greater is the work on the brain to fire up the neural circuitry, which further strengthens the brain areas. So remember this adage: “Balance on one leg and fortify your brain!”

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Friday Q&A: Yoga Teacher/Stroke Survivor

Q: I am a yoga instructor and a stroke survivor as well. I know, I know, a yoga instructor AND a stroke survivor. Fancy that! I have a compromised left shoulder and it's getting much worse. Have had it for 6 years. This is the problem: my right side of my body is also compromised but in a different way. It's just less. Little shoulders and most of all hands. It's just less. Imagine what my yoga classes are like, little demonstration. My questions. How long would a person be totally on foot before I would have to do little thing alone? How long would I teach yoga class? When is too much complications you say above is more serious? Anything else you can think of. Also, the article Yoga and Shoulder Joint Replacements was truly wonderful.

A: I am not exactly sure I understand your question but my initial response is you should teach as long as you have students who will come. But maybe your question is more about mobility and how long will you be able to walk "on your feet" and if you can't walk, can you still teach? Again, as long as you have eyes and a heart and can use your language to convey intention, then you can teach, as long as you have the endurance. With all chronic disabilities, and especially strokes, fatigue is a big factor. Sometimes the struggle to do all the little things of life are overwhelming and then there is no more energy left for other things. If your situation is such that fatigue is a factor, can you have an assistant that you train to do the physical adjustments for your  students and perhaps the physical demonstration? Your expertise is why people come. I personally don't feel that a teacher has to demonstrate. My teacher, Donald Moyer, doesn't demonstrate much, and if he needs something modeled he chooses a student that he can use to convey the concept he is teaching for that class.

I think chronic illness makes you more adaptable because you can't do things the old way, and have to create new ways. So it might be an interesting teaching tool for you to teach your students what your body feels like to teach compassion. Acceptance is a big deal with acute illness as well as with chronic illness. Learning to accept changing body images as not “limitations” but variations is a powerful lesson.

Also, the complications referred to in the post Yoga and Shoulder Joint Replacements were for the post-operative period. In a shoulder joint replacement, they are reattaching tendons and repositioning muscles to do other jobs.This is why I said that trying to work too vigorously too quickly following the post-operative protocol can lead to serious complications in the success of the surgery. But you are alluding to pain from a stroke, as well as increasing dysfunction on the other side. This is very common because when one arm can't do, the other arm does more and overuse develops. Being referred for a total shoulder replacement is not common as there aren't a lot of docs who do them and do them well. Dysfunction from a stroke with loss of motion is not the same thing. I recommend that if you have access to health care, you see a physical therapist or occupational therapist who specializes in the upper extremity (this includes the shoulder, elbow and hand) to get a holistic view of your  movement and movement patterns. From there you can be more specific in your questions of your physical mobility and continuation of teaching yoga.

I hope this helps. Please let me know what happens!

—Shari

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The Power of Fact Checking: Timothy McCall on Elephant Journal

by Nina

Buddha Waiting for Spring by Michele Macartney-Filgate

Just a quick announcement today to let you know that Timothy has a very interesting post up now on Elephant Journal Does Yoga Kill?

Recently Timothy wrote about yoga and strokes on our blog (see Will Yoga Cause a Stroke? Could It Prevent One?), covering the topic in general and how to practice yoga safely. In his Elephant Journal post, however, Timothy directly takes on New York Times science writer William Broad’s claims about the relationship between yoga and strokes, responding point by point to Broad’s claims and looking more deeply into the research that Broad used to back them up. All I can say is, wow, that fact checking thing is really amazing—wonder why Broad's editors didn’t avail themselves.

My favorite fact is this one:

“To bolster his case, he listed several people whose deaths might have been caused by yoga including this one: “In Los Angeles in 2004, Sita White, 43, a British heiress and a favorite of gossip columnists, collapsed and died in a yoga class. The question is why.”

What Broad neglected to mention is that she wasn’t doing yoga at the time. According to eyewitnesses and media reports, White collapsed and died while students were filing in and putting down their mats.”

I also love Timothy’s conclusion:

“The truth, on the other hand, is often complicated, nuanced, and doesn’t always make a great story. And it is precisely that satya—subtle, interpenetrating, endlessly unfolding—that yogis are after.”

But you should go ahead and check out this article! And let us know what you think.

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Will Yoga Cause a Stroke? Could it Prevent One?

by Timothy

There has been concern—and for some even fear—in the yoga community regarding the risk of strokes from doing yoga. How realistic is this?

Much of this fuss was set off by the New York Times writer William Broad, who warned that all the stretching of the neck in various yoga poses like Cobra and Shoulderstand could lead to tearing of the linguini-like vertebral arteries that run along either side of the neck bones, which could then lead to bleeding into the brain. But as I (and others) have written (see Man Bites Down Dog), Broad's analysis was alarming, lacked data to back his extraordinary contentions, and in all likelihood was way off. Still, it may be worth discussing the risk of strokes and what thoughtful yoga practitioners and teachers can do to prevent them.

Arteries of the Neck (from Gray's Anatomy)

Vertebral artery tears and resulting strokes often happen when someone makes an unaccustomed neck movement. The example that is often cited is when an elderly woman drops her head back into the hairdresser’s sink. In such a case, the movement in question is an extension of the neck (the cervical vertebrae), not so different from what happens in backbends like Cobra pose and Upward-Facing Dog. But it’s also at least theoretically possible to tear the artery when you go in the other direction and flatten the neck vertebrae, as in Shoulderstand and especially Plow pose. Even twisting poses could cause problems if you crank the head too far. Outside of yoga, such strokes also have been reported to happen when people simply turn their heads to the side or suffer minor trauma. It is estimated that 1.5 people out of every 100,000 suffer vertebral artery-related strokes every year.

I have observed many yoga students who hyperextend their necks in poses like Cobra and others who flatten their neck in poses like Shoulderstand and Plow. In the case of backbends, many students have the habit of over-arching from the neck. They compress the backs of their necks, and often arch too much from the back of the skull (the occiput), at the atlas-occipital joint. (The atlas is another name for the first cervical vertebra.) This habit is common in those with tight thoracic spines. When the thoracic spine is stubborn, people sometimes overcompensate by overarching the more flexible cervical and/or the lumbar spines. In other words, when one link in the chain is tight, people tend to move more than they should from the links above and below it.

When instructing backbends, I encourage students to try to keep the back of the neck long. Rather than looking up in a pose like Cobra, I encourage those with the habit of neck hyperextension to keep their gaze forward, which tends to keep them from tipping the head back too much. It’s also useful to think of originating the movement in your neck from the middle of the thoracic spine and the lower cervical vertebrae (where the neck attaches to the back).

Poses like Shoulderstand and Plow pose tend to flatten the neck. This is especially problematic if the student tries to move the chin towards the chest (an unfortunate instruction that some yoga teachers use). Instead, I encourage students in these poses to lift the front of the chest toward the chin, and actually slightly move the chin away from the chest. If you try this, you may notice that it lessens the feeling of pressure at the back of the neck.

In the traditional hatha yoga Shoulderstand, known as Viparita Karani (not to be confused with the restorative pose that uses the same name), the legs are in a jack-knife position. In other words, the pelvis is behind the spine and the feet are forward of the spine. This pose can be done safely without any props, especially if you follow the instructions of moving the chin slightly away from the chest. This is the version of Shoulderstand I’ll do if I wind up somewhere with no props.

Rare is the yoga practitioner who is flexible enough to do the modern, more-directly vertical version of the Shoulderstand—in which the legs are stacked directly over the hips and shoulders—without blankets or other props to raise the shoulders off the ground. To keep suppleness in your neck, the number of blankets required varies. For example, I use four folded blankets under my shoulders. Try to place your shoulders near the edge of the folded blankets so you graze the skin over C7, the lowest cervical vertebra, while you work to lift C7 away from the ground. Your breath should be soft, slow and even throughout the pose, and if at any point you can’t breath smoothly, or otherwise feel uncomfortable come down.

Plow pose is even more challenging to the neck, and I recommend the same blanket set-up. If you notice any discomfort at the back of the neck, however, I recommend either skipping the pose entirely or placing your feet higher, for example, on the seat of a chair.

In twists, try not to lead with your head. In other words, the turn should come from the vertebrae all along your spine, with no twist whatsoever from the atlas-occipital joint. One instruction I give if students feel any tension in the neck is to turn the head ever so slightly (say 1 millimeter) in the opposite direction of the twist. What this accomplishes is to stop people from trying to twist the skull on C1, a motion those joints are not meant to do. Even more conservative, is to not let the chin turn any more than the chest, in other words the nose and chest point in the same direction.

Beyond lessening the theoretical risk of a vertebral artery stroke, all the above advice will also tend to help avert yoga’s contributing to such musculoskeletal problems of the neck as arthritis and overstretching of spinal ligaments. Indeed, averting these problems is actually my primary reason for recommending doing the poses as I suggest. Broad generated tremendous publicity for his book by trumpeting the risk of vertebral artery strokes, and made the absurd, entirely unscientific calculation that yoga causes 300 strokes and 15 deaths per year in the U.S. My guess is that it’s more like in a one in a zillion scenario. 

Ironically, skillfully practicing the very poses that Broad recommends avoiding might actually lower the risk of the vertebral artery strokes. When you gradually stretch the arteries and surrounding tissues as could be expected with a regular yoga practice, the vessels would likely become more pliable, and resistant to tearing with sudden movement or trauma.

And the bigger picture is that vertebral artery strokes are a tiny percentage of all strokes, estimated to strike 269 people per 100,000 every year. Yoga’s documented ability to lower blood pressure, cholesterol and stress hormones, reduce inflammation, thin the blood, etc., in all likelihood greatly lowers the incidence of all types of strokes—as well as heart attacks and a host of other conditions. Just be sure to be mindful of contraindications. So, for example, if you have poorly controlled high blood pressure, you probably want to avoid inversions like Headstand entirely. The risk of having a stroke as a result is probably small, but it’s better to err on the side of caution.

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Recovering from Strokes with Yoga

by Baxter

Flowers in a Rock Crevice by Michele Macartney-Filgate

I recently received an email from a recent graduate of a yoga teacher-training program who is looking for more guidance in how to work with her students who have suffered a stroke and are attempting to recover some of their lost function. She happened upon a piece I did for Yoga Journal Magazine a number of years back (see here) and found it useful, but wanted any additional advice I could provide. Seemed like a good topic to share with all of our readers here, so let’s start by defining stroke.

According to the Mayo Clinic: “A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and food. Within minutes, brain cells begin to die.” Stroke is considered a medical emergency that can result is severe disability and death, so it is one of those conditions that need immediate attention. And in the span of time since I began practicing medicine, some significant changes have taken place in the acute treatment of stroke that have gone a long way in improving one’s chances of a better outcome. In fact, in the last 15 years the risk of dying from a stroke has dropped significantly. Better care of the risk factors associated with stroke, such as high blood pressure and cholesterol and diabetes, may be playing a role in these improvements, too. However, getting to a hospital immediately if you suspect stroke is the number one thing to do once symptoms show up.

Once a person has had a stroke, there are innumerable changes that can occur, including trouble walking or even balancing easily on two feet, trouble speaking or understanding what others are saying, paralysis or numbness of the face, arm or leg on one side of the body, or trouble seeing in one or both eyes. There can be mild, moderate or severe mixes of these various deficits in stroke survivors.

Despite the huge changes that can arise for someone who has suffered a stroke, new understanding of how the brain works provide encouragement that what was once considered a largely unchangeable thing (the brain) is now known to be highly changeable. This concept is known as “neuroplasticity.” According to well-known writer and neurologist Oliver Sacks, M.D., neuroplasticity is “the brain’s capacity to create new pathways.” There are now NIH studies looking at the brain’s ability to learn and grow new neural pathways after damage that are quite encouraging. And since physical therapy is considered an essential treatment for post–stroke recovery, yoga asana can supplement this quite nicely. And yoga may work because someone new to yoga is “learning” new patterns of movement, new skills of observation, as well as learning a new language, Sanskrit, and new verbal patterns, via memorizing yoga sutras and learning chants. So the brain is being maximally stimulated to lay down new neurons in many if not all of the areas that have been negatively impacted by the stroke.

As I have previously recommended, modifying asana practice via doing reclining pose variations either in a bed or on the floor if the patient can easily transfer up and down is quite helpful in situations of extreme weakness or balance problems. Another way to work if standing is still dicey is to do a chair-based practice, with one or more chairs available. A huge variety of poses can be done safely in this way, including clever modifications of sun salutations. I’d direct you to several books for more ideas, including Nischala Joy Devi’s The Healing Path of Yoga, and Sam Dworkis’ Recovery Yoga. Although not specifically written for stroke recovery, many of the ideas presented could be nicely adapted for this setting. And for those with more ability to do standing work, the use of the wall for supporting various body parts while doing any number of standing poses could be the next step in progressing students towards more normal physical functioning.

In addition, as way of working with the cognitive loses that can result from stroke, working with mantra, chant and pranayama could be quite helpful for most students. Always start off with simple variations of these things. Encourage regular, repeated practice outside of class once the student has learned the new “pattern.” It is really the participating in a discipline that may ultimately lead to the positive changes we would hope for our students who have had a stroke. Another modality that may help is certain “eye exercises” that have made their way into modern yoga classes. And although I don’t have a lot of personal experience with these, you could seek out a teacher well versed in such techniques to learn and share with your students.

In addition, due to the fatigue associated with stroke, as well as the mental-emotional stresses that arise, restorative practices and yoga nidra can play a wonderful role in supporting the work of the other tools of yoga you have already introduced to your students. And for teachers just starting out, you often have been given very limited exposure to working with students with special needs, such as stroke survivors. So, I highly encourage you to look for workshops and post-graduate therapeutic training opportunities to increase your skills and competence in working with these special folks. I may return to this topic in the future, but for now, this should give you some ideas to start working with right away. All the best in this very worthwhile endeavor!

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