Drawing a Line in the Sand: Where Yoga Teachers Should Not Go

by Baxter and Nina

Silver Beach by Brad Gibson

Yesterday Baxter was interviewed by YogaU (we will announce when the interview is available online, sometime in April), and he was asked to discuss the concept of yoga as “Lifestyle Medicine” looking at its potential and its challenges. One of the challenges that came up during the discussion was something Nina mentioned to Baxter while he was preparing for the interview, and we both realized it was something so important that we decided to share our thoughts with you about it on the blog today.

The challenge is: Where do we draw the boundary between yoga therapy and practicing medicine, physical or other types of rehabilitation therapy, or psychotherapy?

One clear line in the sand we can draw is that yoga teachers should never try to diagnose a medical or psychological condition. This is because we are not trained to do so and, in fact, are not legally permitted to. This means if a student comes to you with a complaint that has not been formally diagnosed, you must refrain from offering an opinion as to what could possibly be wrong. However, as you are in an influential position, you can—and probably should—encourage your student to go and get a diagnosis.

Once you have the diagnosis, if you’ve had proper training in yoga therapeutics, you can then make suggestions for yoga tools that could help your student. This is where you come into your own! Yoga has an enormous repertoire of different physical movements—some not available through other forms of exercise—that can be of tremendous benefit to a large number of conditions. Teaching asana to release held tension, build strength, increase flexibility, and improve balance and mobility provides a powerful approach to healing that western medicine typically doesn’t include. And teaching stress reduction techniques can be tremendously helpful for a number of both physical and psychological problems.

If you don’t yet have a diagnosis but the student’s complaint seems like one of those problems whose symptoms can be relieved by yoga, such as back pain, muscle soreness or joint stiffness, you can suggest some possible poses without promising any particular result but being willing to stay open to see what happens. An undiagnosed back pain, for example, might be relieved by general low back practices but also might not be if there is a serious underlying condition. If the complaint seems like one that would be helped by stress management, such as anxiety or insomnia, you can always offer relaxation techniques, as these are safe for anyone. And, finally, as Nina wrote yesterday in Yoga to Reduce Suffering, we can always offer possible suggestions for reducing suffering. But this is all with the understanding that if the problem persists, the student should consult a professional.

Conversely, if you are a student hoping to get some help from a yoga teacher, you need to understand that your teacher is not licensed to diagnose your problem even if he or she is billed as a “yoga therapist." And if your teacher is offering you what seems to be diagnostic advice, you might want to check to see what their training is. If your teacher has additional training, such as Baxter (an MD) and Shari (a physical therapist) do, you might feel more comfortable taking his or her advice. But without a thorough physical examination, even a medical doctor or physical therapist can only make an educated guess, which you should take as a suggestion more than as a definitive diagnosis. (And if he or she does not have additional training, you should definitely be wary.)

And if you want to get the best out of your teacher, go see a professional first and find out exactly what is going on. Then share your diagnosis with your teacher. At that point, your teacher will be free to make suggestions and recommendations that might be very helpful for you, and he or she can also do a better job of keeping you safe in the classroom. Keep in mind that yoga therapists will often have areas of specialty, such as back care, cancer care, or depression, so you may need to find a different teacher or yoga therapist who has expertise your area. The good news is that yoga has been taught in the US for over 50 years, and there are experienced teachers now in almost every part of the country. So after you’ve been to the doctor or therapist and received your diagnosis, if you've taken the time to find a teacher with the right expertise, you’ll have someone with a powerful set of tools to help you on the road to healing.

How’s that for a line in the sand?

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Yoga to Reduce Suffering

by Nina 

II.16 Suffering that has yet to manifest is to be avoided. —Yoga Sutras, trans. by Edwin Byrant

Melitta's post Aging, Diabetes and Yoga  and Shari’s post Ruminations on Health reminded us that although yoga can be helpful for many conditions, it is far from a cure all. Melitta’s life is sustained through western medicine (that is, insulin), without which she would have died. And as Shari said:

My own personal pet peeve is the often unspoken allegation within alternative healthcare communities of “healthy living” that if you lived a more “pure and holistic life,” this illness or health problem wouldn’t be happening to you. Too many women I have known with breast cancer have felt the twinge of anxiety that they were the cause of their own cancers. But how much do we owe to our own genetic predispositions rather than to emotional and environmental stresses?

On the other hand, I think all three of us believe that yoga has something important to offer to people suffering from chronic and even terminal diseases or conditions: the reduction of suffering.

This message came home to me in a very powerful way when I attended a therapeutic workshop on yoga for cancer, taught by Bonnie Maeda, RN. As a nurse, Bonnie has a clear-eyed understanding that yoga cannot cure cancer and, indeed, that even western medicine cannot always do the job. So what she has been offering her students, along with a chance to move and regain strength, is the reduction of suffering. This was especially evident when she led us through a sequence that she had designed specifically for this particular set of yoga practitioners. The sequence—which was unlike any I’d ever seen before—was a gentle Vinyasa series that used the wall for support. Bonnie explained that she felt this particular group needed to engage their minds by moving mindfully from one pose to another as they followed their breath, but, because they were often weak from illness or treatments, the wall was necessary for support and safety. To be honest, I thought the sequence was brilliant! It was providing gentle exercise for people who needed to build up their strength, while at same time functioning as a mindfulness practice to help focus minds on the present and distract from worries about the future.

After the movement came supported poses and relaxation. Stress management is also invaluable for people with chronic illnesses as it can help reduce both physical and emotional pain, as well as supporting healing. As we’ve mentioned before on this blog, yoga provides such a wide range of stress management tools (meditation, breath awareness, pranayama, conscious relaxation practices, restorative poses, supported inverted poses, and active practice to release physical tension) that there is something suitable for almost everyone.

For those of us who are teachers, it is important for us to remind ourselves both of the limitations of what we can offer and of the simple but powerful solutions that we can provide. Both mindful movement and stress management techniques are safe practices that can help reduce the suffering of people enduring great challenges.

And as human beings, it is heartening to remember that there are powerful practices we can rely on when difficulty arises.

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Yoga and Heart Health: Atrial Fibrillation

by Baxter

A yoga workshop to Cincinnati brought me face to face with my first “medical emergency” in the yoga classroom. On the first night of a two-day workshop, one of the students began to complain of a rapid heartbeat and some shortness of breath. I took her off to the side while my co-teacher continued to work with the rest of the group, and discovered, after a few more questions, that she had a condition know as atrial fibrillation. Turns out she had been feeling well lately and had decided to cut back on the medication used to keep her heart rate in a safer range. Fortunately, in this instance, I was able to get the life squad there quickly and shuttle her off to the ER for appropriate care, and the rest of the workshop continued without a hitch. Now a dozen years later, an ongoing study at the University of Kansas seems to suggest that yoga may be helpful in treating this particular heart condition!

So what is atrial fibrillation? According to the National Institutes of Health:

“Atrial fibrillation (A-tre-al fi-bri-LA-shun), or AF, is the most common type of arrhythmia (ah-RITH-me-ah). An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. AF occurs if rapid, disorganized electrical signals (emphasis mine) cause the heart's two upper chambers—called the atria (AY-tree-uh)—to fibrillate. The term "fibrillate" means to contract very fast and irregularly.”

Sometimes, people who develop this condition notice the rapid, irregular beating of the heart, but sometimes it can go unnoticed for a while. And two very serious conditions can result from untreated atrial fibrillation: strokes (which occur suddenly) and heart failure (which develops more gradually). The underlying problem has to do with the heart’s electrical system not functioning correctly. And because the normal spread of the electrical impulses is both too fast and uncoordinated, the heart becomes both less efficient at sending blood out to the lungs and the body, and blood tends to pool or hang out in the heart chambers longer than it is supposed to. This pooling can lead to blood clots forming in the chambers of the heart, which could then be launched into the arteries that lead to the brain, and—whammo!—a stroke occurs. For more information about AF, check out What is Atrial Fibrillation? from the National Institutes of Health.

Back to 12 years ago, when I was confronted with someone who was having acute symptoms of her rapid heart rate, I needed to get her to a facility that could quickly get her heart rate in a safer range and make sure she was not at risk of a stroke. And I did not have information then on how yoga might impact the course of her problem. Now, research being conducted in Kansas is suggesting that yoga may be a part of the future treatment of AF. At the University of Kansas Hospital, an ongoing study is looking at the effect of regular yoga practice on irregular heartbeat. The yoga world has long known about the connection between yoga meditation and breath techniques and the ability to influence the heart rate. This connection between the mind and the heart is at the center of the theory on how yoga may help with AF. Via yoga’s ability to influence and change the autonomic nervous system, patients may be able to have more control over their heart rate than those who do not do yoga. It is also known that stressful situations and emotional moments can trigger the AF person’s heart to beat more rapidly. So the researchers are monitoring the study participants for how many episodes of recurrent AF happen while on the yoga regimen. They report that the initial results look promising.

AF is one of those medical conditions where a combination of modern western treatment, which includes medications that help control the rate and rhythm of the heart and procedures to help if meds don’t, and lifestyle modifications, like yoga as well as diet and other exercise, will optimize the health of the person with AF. The study is not yet completed, but we will try to keep an eye open for the final report and give you an update when that happens. In the meantime, see Yoga My Heart  for more about the University of Kansas Hospital study.

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Ruminations on Health: What We Can and Cannot Control

by Shari

Branches by Brad Gibson

I grew up in an eastern European Jewish household where dinnertime conversation often centered around health. Family gatherings were punctuated by relatives recounting details of various  ailments and how many doctors they were seeing. They were often pretty graphic in their descriptions during these mealtime conversations. My family’s preoccupation with their bodily functions struck me as odd as a child, and I didn’t understand how people could complain about their health but not really do anything about it. I made a conscious decision at that time to be proactive with my own health, and my lifestyle decisions and pursuits since then have reflected this.

Now I'm at the age where I am regularly receiving AARP notifications, and I'm starting to reflect on how I may be more like my parents and family than I may like to think. How many of you regularly talk with your friends about your health concerns or routine tests that a physician may be prescribing or recommending? We talk about these issues partly to become informed about procedures, but also to commiserate and offer support and empathy when complications occur. We often compare notes on which care providers have been helpful to us. There have even been times where I have looked up providers on YELP to see what their ratings were. During the AIDS epidemic in the 1980’s, my husband and I lost many friends, so we learned that illness isn’t just for “old people.” And how many of us have lost loved ones and acquaintances to cancer or other chronic diseases?

In the yoga community there are many passionate individuals who believe whole-heartedly in a way of health that I feel is fairly rigid. My own personal pet peeve is the often unspoken allegation within alternative healthcare communities of “healthy living” that if you lived a more “pure and holistic life,” this illness or health problem wouldn’t be happening to you. Too many women I have known with breast cancer have felt the twinge of anxiety that they were the cause of their own cancers. But how much do we owe to our own genetic predispositions rather than to emotional and environmental stresses?

My mother, for example, died of multi-infarct dementia, which caused severe dementia in her last years. She was a cholesterol producer, and no amount of dietary restrictions or faithfully taken statins could keep her cholesterol levels within “therapeutic ranges.” And lo and behold, right after I turned 57 and went for my annual physical and blood work, my doctor contacted me to tell me my “bad cholesterol levels were high.” With further blood work, using more sensitive lipid panels and getting a more complete picture, my numbers came back better. But I was still demonstrating risk factors, so my doctor counseled me on good nutrition (which I already practice), exercise (which I already do), and stress reduction (which I already do). She then commented to me, “Well I suppose this is where your genetic history is coming into play and we just have to watch it.” Oh dear, I thought, now what?

In Melitta’s recent post Aging, Diabetes and Yoga I was struck by her self education regarding Type 1 diabetes, and how she had to play an active role in her healthcare management, even educating her physician on the nature of her disease to get a proper diagnosis. Her story emphasized the need to be involved in your healthcare decisions and not be passive in accepting what “experts” tell you. But it was also inspiring to me because here was someone who was both realistic about her condition (yoga cannot cure Type 1 diabetes) but who at the same time found yoga invaluable for helping her live with (and work with) a chronic condition.

It got me thinking about my own situation. I considered becoming more restrictive with my fat intake, but then concluded it would lead to more stress in the long run. I came to the conclusion that I had to accept my genetic heritage. No, I wouldn’t become like my extended family and bemoan the state of my health, discussing it whenever the opportunity arose while taking no responsibility for my actions. Nor would I become strident in regimenting my life with countless restrictions and intentions. Instead I decided to mindfully continue to engage in activities that made me feel good while maintaining an awareness and consciousness of what and when I ate. As in my yoga practice, I will aim for balance and intention. My genetics are a big factor in my health, but my lifestyle and personal practice of yoga seem to be potent tools that I can use in accepting my genetic hand of cards!

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Friday Q&A: Bypass Surgery

Q: I have a 65 year old male student who is having open heart surgery in a couple of days. He will be having a triple bypass with valve repair/replacement. How long (approximately) will his recovery be before he can come back to a Yoga Basics type class where we do basic postures and sun salutes? What will be the main cautions for me to be aware of as a teacher? Will his breathing be impaired? Thank you for your guidance.

A: As you might imagine, there are a lot a factors that will play into how quickly your student might return to a typical yoga asana practice after such a major surgery. So, his clearance to return to yoga will be entirely up to your student’s heart surgeon and post-operative care team. In all likelihood, he will have some physical therapy to guide him back to activities, as he will have a major chest scar that will take a while to heal. In addition to the chest scar, your student is also having a valve in the heart replaced, and will likely be on blood thinning medications for at least the short term. This can lead to bruising easily.

Cow-Face Pose Arms

 As for main cautions to be aware of as a yoga teacher, as with most situations, you want to meet your student where he is at on any given day. It would be helpful to meet with your student for at least one private session to try out some very beginner, basic movements that would likely show up on class. Keep in mind that anything that engages the muscles of the front chest, either contracting or stretching, will affect the healing breastbone area. So go slowly with things like arms overhead, out to the sides, or behind the torso. Be very mindful of more advanced positions for the arms, such as Eagle pose or Cow-Face pose arms. Lying on the chest may not be possible for a while, so keep that in mind when doing prone poses like Locust or Cobra. He may have to do a seated or standing variation of such poses. And back-bending postures will likely need to be much shallower then pre-operatively.

And for the possibility of bruising easily, you will want to mindful of poses where you are placing body parts on to one another, like the modified version Extended Side Angle pose (Utthita Parsvokanasana), when the elbow is placed on the distal thigh of the front leg. If the student does this pose without mindfulness, he could get a big bruise there, and although this is mostly of cosmetic concern, preventing it from happening will probably be much appreciated.  Stacking the legs, such as in Fire Log pose (a preparation for Lotus pose) is another one to watch out for, and you can probably come up with others as well.

On the positive side of the ledger, if the surgery is successful and the student’s heart is working more efficiently, it will not only positively impact his cardio-vascular fitness, but also should have a beneficial effect on his respiratory status as well. Gentle breath work, taking into account that the stretch of the rib cage area could trigger some pain, can be introduced pretty early on, if his surgeon gives the green light. In fact, pranayama and meditation practices could likely be started pretty soon after surgery, as they primrily require mental focus and concentration rather than physical demands. Good luck, and feel free to let us know how his return to yoga progresses!

—Baxter

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Labor of Love

by Nina

A question we frequently get asked is: why don't you have ads on your blog?

Another one is: how does your blog make money?

The answer to both questions is: This blog is a labor of love. For our love of yoga. And for our love of the yoga community.

So thank you, dear readers, for your companionship on the journey!

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How Much Stretch is Enough?

by Baxter

Reclined Leg Stretch

Last week I looked at the concept of “compression” both as a perceivable event in your body and as a potential problem for your body when doing asana (see Tension Versus Compression). After that post, one of our readers requested information about the other sensation producer, muscle tension, and the usually desirable event that occurs when we do asana, stretching in the muscle.

In the vast majority of our yoga classes in the US, we are continually asked to notice the sensations arising from the various yoga asana as we perform them. We are encouraged to find our “edge,” a place or perception of muscle stretch before which we don’t feel much, and beyond which we feel too much or begin to encounter pain. We are led to believe that stretching our tight muscles is highly desirable, but often are not clearly told where the “finish line” of this process might be. So how much stretch is the right amount? How much is too much? And how can we tell the difference? I have an opinion on all of these questions, but I took a look around to see if there was any objective evidence that might give more credence to my opinions.

The first interesting article I came across was How Necessary is Stretching? a New York Times article from 2009. Here Gretchen Reynolds reported on at some new information about stretching that had just been discovered. One study looked at a group of runners at a university in Nebraska. Researchers measured the runners' hamstring flexibility, then compared hamstring flexibility to a measure of their success as runners (known as “running economy”). They found that runners with tighter hamstrings were actually faster and stronger runners. Reynolds noted that, “In fact, the latest science suggests that extremely loose muscles and tendons are generally unnecessary (unless you aspire to join a gymnastics squad), may be undesirable and are, for the most part, unachievable, anyway.” She went on to quote a sports medicine expert:

“To a large degree, flexibility is genetic,” says Dr. Malachy McHugh, the director of research for the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York and an expert on flexibility. You’re born stretchy or not. “Some small portion” of each person’s flexibility “is adaptable,” McHugh adds, “but it takes a long time and a lot of work to get even that small adaptation…””

This made me consider what purpose my yoga “stretching” was for. I tend to think that stretching is going to give me more success and less discomfort in performing my asana. The above article did mention one benefit of a regular stretching of the muscles. If done regularly, even if the length of your muscle does not change much, your perception of the intensity of the stretch sensation diminishes. In other words, you don’t feel so tight anymore. So stretching regularly will make your asana more comfortable, and if you are practicing asana to prepare for seated meditation or pranayama, you will also find it easier to sit comfortably on the floor.

For healthy aging, stretching is important for maintaining flexibility as you age. Without regular stretching, your muscles will become stiffer, potentially interfering with your ability to go about the normal activities of daily life, including dressing yourself, driving, walking unassisted and even getting in and out of a chair (see Transferring and Yoga), and can impact your ability to balance. For all these reasons, stretching is very beneficial for you whether or not your muscles actually become more flexible.

Before I go much further with that train of thought, let’s look at what else I found. When a muscle is stretched, it not just the muscle cells themselves that do the elongating, but also the connective tissue or fascia that surrounds and penetrates each muscle of the body. Where the muscle has pretty amazing ability to elongate and contract and change size dramatically, the ability of the fascia is more limited, even when it contains some elastic cells. And when the connective tissue is over-stretched, it can lose its supportive properties for the muscles and lead to increased chance of the muscle itself getting micro-tears that heal more slowly. In addition to the fascia, the other connective tissues, such as the tendons that attach the muscle to bone, are more vulnerable to injury as well.

So, I think common sense regarding stretching muscles is to work up to a point discomfort, but not into frank pain. Try to get the sense of stretch in the center of a long muscle and try to avoid sensation closer to its bony attachment at (or near) the joint.  On occasion, you will know you have overdone it by the sudden quality of pain that accompanies your stretch, but often you won’t know until the next day, when inflammation sets in and the pain is there more persistently. Shoot for taking your stretches slowly and mindfully, keeping your personal goals in mind as you work in your poses.

And as Paul Ingraham points out in The Unstretchables: Eleven Major Muscles You Can’t Stretch, No Matter How Hard You Try, some muscles aren’t actually stretchable the way muscles like the hamstrings—which are quite literally made for stretching—are. I know there are a lot of thoughts on this topic out there, so feel free to add your insights here. I believe in our collective wisdom!

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