Does the concept of yoga relate to the diagnosis of Stroke? Does yoga as used with post-Stroke clients, complements their health care process? I invite a discussion to explore these questions as they relate to application and adaptation of yoga for the stroke population.
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Yoga should always be presented as a discipline, which includes a physical aspect, that meets people where they are. Becuase of that, we should be very careful about saying what "poses" would work for a stroke survivor; every one is different, not just in the way they presnt post stroke, but also in their premorbi condition and personality. The whole person should be taken into consideration. Only a teacher who is able to look at an individual body and, along with the owner of that body, figure out what might work, then modify and adjust as necessary, should be teaching yoga at all, and especially to someone who is in a compromised physical and emotional condition. I have worked with many, many stroke survivors over the years, and there is very little that we can generalize to all of them.
love,
molly
Thank you Molly for your comment and stressing the wholistic approach that should be the basis of any intervention. But for sake of the discussion and as a clinicians who is seeking to understand how to apply yoga into practice, I wonder which key principles hold a promising place when working with stroke clients. My current area of intervention at this time is acute to subacute phases of the diagnosis and thus I have a rehabilitative goal. But, I know that yoga holds a promising prospect in chronic stages too. Thinking of the basics (even before the poses), what are the key elements of yoga that one should be mindful of?
Thanks
Rashmi
I have not used yoga specifically for stroke yet but some of my reflections on yoga can be found here: http://www.metaot.com/topic/yoga
V
The diagnosis of stroke is certainly of form of loss/re-identification...which of course Yoga is the science of accurately identifying "reality". Many of these "acute" issues are brushed by in acute care...by all but the patient, for whom they are acutely present. I'd advise reading Matt Sanford's Waking as he has much to say about how rehab treats a mindbody lesion like CVA. I'd also recommend my spouses recent article in the IAYT journal of Yoga Therapy 2008 on End of Life...while stroke doesn't have to be fatal, the old "life" does die and the issues that surface are the stuff of Yoga.
thanks for starting this important discussion!
matt
Thanks for the input from the previous bloggers on the holistic and spiritual aspects. My perspective is that OT and yoga share many similar philosophic, practical, and holistic approaches. Both emphasize the importance of developing a rapport witht the client, meeting the client where he/ she is, and employing therapuetic use of self to develop a plan and continually reasses/ modify it with feedback.
From a very concrete perspective, I am impressed with how similar many conventional rehab exercises and yoga poses look. That begs the question"what makes it yoga?" The answer seems to be in the mindfulness.
My suggestion for rehab therapists who want to integrate yoga into their sessions:
Have a strong personal yoga practice.
It may not be necessary to be a yoga teacher, but be competent in demonstrating a yoga pose or technique, analyze the benefit and be able to modify it for the individual. Take a course such as "Integrating Yoga Therapy into Rehabilitiation" offered by DSR:)Stay within your scope of pratice with your licensure laws. Be able to document therapeutic activity and benefit/ progress.
Use the time when checking vital signs to check in on a deeper level. Capitalize on the breath as the link to the spiritual realm, as well as the relaxation response!
Savasana and restorative postures with props are so beneficial to restore the balance and feeling of being whole!
Our clients are more likely to follow a home program that icludes savasana and restoratives!
Namaste,
Pat
Svaroopa Yoga is a relatively unknown branch of Yoga developed by Rama Birch, who acquired very subtle knowledge about the healing energy of the body (prana) and the asanas (postures) that open the way for it to flow, from her 14 year path with her guru. As a victim of 2 car accidents, which resulted in injuries along her spine and cervical area, she acquired deep knowledge of what is needed for effective healing in these areas. The postures used in Svaroopa Yoga differ from all other forms of Yoga in these main qualities:
1. Svaroopa uses a Yin approach to the postures, ie. NONE of the asanas require muscular effort. In fact, the first goal of every posture is to release/alleviate as much muscular tension as possible from the limbs, to reduce muscular tension along the spine so that spontaneous openings can occur. For this reason, the alignment of the postures must be very precise, with blankets and cushions being used to position the spine and limbs to release the most tension. The result is a very effective calming of the nervous system and mind, and releases of muscular tension along the vertebrae that can last several days, promoting increases circulation to and from the affected areas. In the non-physical body, the blocks that prevent prana from flowing freely to areas that need healing are removed. Flexibility of the spine increases over time; stress is greatly reduced, allowing homeostasis to be re-established and healing to occur; a meditative state is often brought on by the postures, allowing deep relaxation and the development of Awareness, a tool used for improving stress management.
2. The asanas can be done comfortably, with appropriate assistance, by ANYONE, including stroke victims, those with partial or full paralysis of the limbs and those with limitations in mobility or flexibility resulting from injury or lack of practice/experience. They can also be done in beds and chairs, if working on the floor is not possible.
3. Asanas are ordered in such a way as to produce sequential openings from the base of the spine (root chakra) to the top (cervical/neck) area. Relapse (muscles re-tensing along the spine) is avoided by precise timing of the postures.
If you would like to know more about Svaroopa Yoga as a form of therapy, please contact me at http://bablends.ca.
Namaste
Mr Matt, you raise an interesting point. As a matter of fact, I have read "Waking" by Mathew Sanford. I am trying to get hold of the article by Jennifer Taylor you reference. But, the essence of your post is integration. Stroke creates a dichotomy of the body image, lack of communication from one side of the body in addition to other deficits. So, you highlight here that yoga can help with that bilateral integeration and help a client establish that sense of wholeness. Many of the rehabilitation practitioners would be able to relate to this point along the concept of re-education or compensatory approach to rehabilitation. U teach a client to compensate for the deficits by doing all with the intact limb or your intervention helps promote attention to and integration of the affected extremity.
So, for the benefits of others, would you be kind to elaborate how yoga can be used to promote that integration, enhance attention to the immobile side of the body, and restore a symmterical body image.
Thank you
There are many aspects of Yoga including physical, mental and spiritual. Yoga literally means to "yoke" together. In order for a yoga OT session to be most effective, I believe that it must be multi-faceted. You cannot just have a client perform a few asanas and call it yoga. I have been fortunate in being able to combine yoga techniques into neurological rehabilitation with persons with brain or spinal cord injuries, CVA's, MS, ect. It is a valuable treatment tool that I incorporate as a tool with the right clients. Sometimes, I only can use Yoga Nidra techniques.
I am currently not working full time but I live a few miles from an Ashram, and I am able to take yoga classes and yoga nidra classes several times a week.
I am hoping to take yoga teachers training classes soon with the hopes of adding those credentials to my therapy toolbox. I love combining ancient techniques with modern day therapy! It makes so much sense, and is great therapy!
I realized I should also note that Svaroopa Yoga as a practice and approach (asana and beyond) UNIQUELY addresses the imbalances of the Doshas that are the creating SOURCE, and are created as a result of, these dis-eases and traumatic events - not just the physical aspects of stroke, paralysis and spinal injuries that Western medicine is familiar with. No other practice addresses all of these aspects, all of which are needed for complete Healing.
As for the many other important details, they are best discussed individually. I can be contacted directly at http://bablends.ca
Namaste
Ms Barnes,
Thank you so much for your comment. It seems like mindfulness and breathwork are the key and distinctive features. Sometimes, there is limited or inadequate follow-up especially in acute care settings. Developing efficeint breathing requires practice or abhyasa. I wonder if there are any potent techniques or set of instructions that one can deliver to the client (when time is constrainted) to facilitate reasonable grasp of the concept?
Thanks
RAshmi
Pranayam, outside of re-establishing 'normal' breathing patterns (eliminating shallow breathing, for example) is actually UN-Balancing for stroke victims. Prana in the subtle body is known as Vata in the physical body, which is the imbalance that predominates after, and before, a stroke. Pranayam techniques would not be the best therapy for stroke patients.
All Svaroopa postures need to be done in sequence, ie. from the base of the spine (coccyx) to base of the neck, as tension at each point along the spine creates tension above it. This is pawanmuktasana, Svaroopa-style (http://bablends.ca/images/pawanmuktasana.jpg), ie. with bolstered support under the knees and under the head, as needed. As much muscular tension as possible is removed from the limbs through the use of alignment and bolsters. The bolster is made up of folded/rolled blankets, high enough to minimize the gap created by the arch in the lower back (sacrum area). The knees are held along the centerline of the body by the deadweight of the arms wrapped around the knees and proper positioning of the extended leg on the bolster. Chin is tilted toward the chest, to maximize extension of the spine through the cervical area (back of neck). The deadweight of the arms pulls the knee closer to the chest over the 4 1/2 minutes (max) the posture is held, stretching the hamstrings/groin area. The student is asked to place their attention on their breathing, allowing it to be natural and focusing on completely exhaling, and scan their body, consciously relaxing any areas where tension remains. The most grounding posture for releasing/opening the Root chakra (Earth element) and Balancing excess Vata in the form of misfiring nerves, tension, poor digestion (IBS, constipation, gas, etc.), anxiety/fear/vrtti (busy mind) and poor circulation to legs, bringing Peace to mind and body and opening nadis (energy channels), to allow easier flow of healing prana.
Ms Belinda,
Thank you for your posts and detailed description of Pawanmuktasana. U already detail the benfits of such a release. With regards to doshas, I read more and deduce how excess of kapha and vata lead to arteriosclerotic changes and consequent hypertension which could very well cause stroke (http://books.google.com/books?id=zhRyW-vnXL4C&pg=PA369&lpg=PA369&dq=dosha+imbalance+and+stroke&source=bl&ots=I1RrsSgjsG&sig=WtWuTwyXyqC3FzFomy0E1AmM4d0&hl=en&ei=OGLdSZr6JYHaMYXtgOAN&sa=X&oi=book_result&ct=result&resnum=). So, you say that developing efficient diaphragmatic breatihing and awareness of breath during activities holds place with stroke clients from pranayam standpoint? Thanks
Ms Kimberly,
U mention about Yoga nidra. I found interesting points about that which help define the place eof this technique with stroke clients. The following quotes from ana rticle by Gervasi (http://www.yogajournal.com/health/1372) sums it well.
"Yoga Nidra is a systematic method of complete relaxation, holistically addressing our physiological, neurological, and subconscious needs."
And "Yoga Nidra uniquely unwinds the nervous system which is the foundation of the body's well-being."
I recall how lot of clients I see in acute care talk about restless nights (lot of time attributed to being in the hopsital) and also extreme fatigue.
The technique needs an experienced teacher to guide the client. Any advice on how to introduce this to a client in hospital setting?
Regards
RAshmi
Yes, Rashmi, I do agree that 'developing efficient diaphragmatic breatihing and awareness of breath during activities holds place with stroke clients from pranayam standpoint'... but that is the extent of pranayam that should be performed. Kapha is VERY rarely the cause of arteriosclerosis - Pitta is usually the root cause, followed by Vata. Prakruti must be taken into account, in addition to vikriti (accumulated imbalances), when prescribing treatment. Kapha-dominant constitutions (prakruti) are rarely found outside Africa, India and other Asian countries. And most stroke patients are over the age of 45, when Vata increases in the body naturally. So it is most important to minimize the accumulation of Vata (prana) through pranayam and to Balance it (as well as Pitta), which is done through Yoga practices which increase Kapha and reduce Vata & Pitta. The one approach that addresses and satisfies ALL these factors is Svaroopa Yoga integrated with Ayurvedic diet and lifestyle (ritucharya).
Namaste
I am an OT and also a yoga therapist - I was actually at a yoga training in Pennsylvania where Molly Kenny was assisting (Hi Molly!). I agree that we cannot generalize in terms of stroke patients except in applying neurological principles of giving proprioceptive and kinesioceptic input and normalizing movement patterns. A few years ago I saw a client about two years post L hemispheric stroke. He had been told by rehab that his progress had plateued and so thay had discharged him. He walked with a limp, his balance was fair and he was still not able to fully use his right arm and shoulder. We began with the warrior postures supported against the wall and with modified hip openers. Within two treatments he noted that he was able to walk out onto his boat (his balance did not enable him to do that prior to yoga therapy treatment). We also worked on weight bearing in table pose and I assigned him to wear a wrist weight on his left arm. Over time these activities affected his fine motor skills and awareness of his right arm. He was able to hold beverages in his right hand (previosly he would drop objects in that hand) and he was able to use that hand to dial a phone. In this client's case, we worked on grounding and weight bearing through the upper and lower extremities and this led to recovery.
Right now I am seeing a young man in his 20s who had a stroke as a result of a heart defect. He was training to be a navy seal at the time. This stroke was of the main artery near the brain stem. That he survived is nothing short of a miracle. When I first met "C" he was extremely uncoordinated in his movements. Being a very tall man, he required both me and one of his parents for mobility when out of his wheelchair. I had him do the warrior poses in the corner of the room with a massage table propped in front of him for added stability. This was extremly labor intensive for C as well as his helpers. His limbs would shake and tremor and we gave him maximum support. On the floor we did downward dog (which he did extraordinarily well right from the beginning), twists to reduce the increased muscle tone, pigeon, table, sunbird, and bow. The hardest of these was sunbird due to his incoordination of his limbs. C grew stronger and more coordinated over time with his core muscles around the hip girdle lagging behind in coordination and strength. We also worked on his breathing - C's breathing had gotten very shallow - pranayama training helped deepen his breath and increase his energy.
When he was not in yoga C worked out on this own diligently, especially with weight lifting and the recumbant bike. He was also attending Physical, Speech, and Occupational Therapy with Health South once a week. I believe all of these efforts contributed to Cs improvement.
I have been seeing C for about 2 years now. We now work in the middle of the room. C is able to do lunges and Warrior 1 in the center of the room with minimal assist. He is able to perform 3-legged down dog and sunbird with minimum assist. To strengthen his control of his pelvic girdle he performs kneeling crescent moons and kneeling hip rotations.
About a month ago, C decided to take a break from physical therapy and continue yoga therapy. He continues to make progress toward greater coordination and control. He has had double vision since the stroke but this has improved over time without specific therapy for the eyes. He has now begun to to read - and not just articles. He is actually reading The Origin of
Species by James Darwin.
I am humbled and impressed by C's progress and determination. It is amazing to me what yoga has done for C along with his own work and PT. C credits yoga as a great contributor to his recovery.
Thank you for your patience with this long entry. I hope it is helpful.
Stacy Renz
Occupational Therapist
Yoga Therapist
Owner, Living Room Yoga, St. Pete, FL www.livingroomyoga.biz
Ms Belinda,
Your expertise as ayurvedic practitioners is exemplified in your post. I had to read up more on the types of doshas and also the concept of "ritucharya", which is adjusting diet and lifestyle to the seasons or the natural course of nature/prakriti. Your feedback helps take concept of yoga beyond the asanas and the physical aspect and defines the wholistic aspect that yoga is. I would like to take the application of this concept to my acute clients and ask your help to summarize the key points. Dosha make of the person is variable, even for "a" person but by and large, pitta is strong along with some vata in stroke clients? One may recommend mild or even cool food, seasonal foods, and avoid black beverages (too acidic). As a practitioner, one could help create mindfulness of the clients to their dietary intake beyond the low fat, cardiac diet categories.
As a clinician, I also make another observation as I read about Pawanmuktasana. Therapist use spinal movemets especially spinal rotatory movement as that helps to normalize the tension/ tone in the msucles as lot of post stroke clients present with increased tone or spasticity. You mention opening of energy channels and flow of pranas with prolonged positional stretch of the spine....
Thanks
RAshmi
ms Renz,
Firstly, thank you for the lenghthy note as it was loaded with information. You highlight commanilities between yogic approach and lot of what is done in conventional therapy with regards enhancing proprioceptive and kinesthetic feedback to normalize movement. It will be extremely helpful if you can spell out what helped make the application of the above-stated concepts successful when conventional therapy was not yielding results. Is it the breath component, mindfulness, or...Marrying that missing link into conventional therapy sounds very therapeutic.
Mr C's accounts is very powerful. You provide certain adapatations as doing the pose in corner, with table in front, and use of manual external support. How long before the results were seen, what was teh frequency of the sessions. Did he have any limb movement at all, I suspect yes as you say he was incoordinated?
The concept of weight bearing, counter poising as in sunbird pose, static stretch and passive range constitute the bulk of conventional approach and yet the gains seem to be more far fetched when same concepts are applied n the realm of yoga therapy.
Thank you so much. Also, if you feel appropriate and Mr C is ok with sharing his perspective as a client and contribute to this blog, I would love for you to extend the invitation to him.
Regards
I find much in common with what was already posted! What I find most juicy and transformative in my work with CVA clients is disentangling some of my own impositions (often well intentioned but not always helpful)on the healing process. I find that when I am in my OT "mode of operation", I am focused on the identification of problems, strategies to better the probems, and goal setting. When I use my OT skills within the breadth of my Yoga practice, I find more ease in identifying what is "right" in the situation and look at ways to foster resiliency, growth, and transformation.
It is of considerable value to encourage ourselves and our clients to be present, and awake with clarity to our current moments as they are. Examining fearful, and habitual thought patterns; looking at how our emotions are displayed in the soft tissue and bony fabrics of our bodies and how we can play with our tone by more spaciously being aware of our emotions/thoughts; and cultivating compassion and willingness to be with one's present condition without looking to "get rid of it" or "go back to the ways things were". Stroke and chronic illness can be incredible catalysts for growth and awareness as we redefine who we are at our very core - and grow intimate with that part of oneself whom is ultimately untouched, unchanged, and unharmed by even the most violent illness or condition.
Posted on behalf of Dalia Zwick
I would like to focus (in my comment) on tone and spasticity issues when integrating yoga in rehabilitation of people post stroke. Rehabilitation professional are familiar with posturing and immobilization of muscles and periarticular tissues as a result of a stroke. Staying in a shortened position results in permanent changes to their structure— called contractures. Contractures are a major secondary problem after stroke. Yoga paradigm, can be used to explain the reasons for these posturing when viewing the body as a hierarchical network of interlocking feedback systems, spasticity which is precuser to contractures, is the manifestation of a body's defense against its inability to mobilize or the instability of its movement. In my practice I focus on something which I believe to be the most important piece in the integration yoga into rehabilitation. That is: ELONGATION of body parts especially those that are affected by the consequence of the stroke. I utilize my understanding of post stroke disability with my knowledge in the intricacy of placing people in yoga resting poses. This anecdotally proved to be an efficient way to prevent of alleviates contractures. It also prepares and helps facilitate active movements when the potential for those movements exists. There is also research that support this (referring to the support of holding people post stroke in positioning that are similar (but not named as such) to the resting yoga poses). Ref: Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial.Arch Phys Med Rehabil 2005;86: 230-4.
Dalia Zwick PT PhD
Senior Rehabilitation Supervisor
Coordinator - The Program for People with Physical Disability
Premier HealthCare
212-273-6100 EXT 2590
ms Diane,
Thank you for your response. I responded to your post yesterday but for some reason I donot see it up here. I will try again.
Your words are very potent here. U raise the point as to what the approach should be, corrective and overcoming impairment or transformative. Moreau, 2001 (see link list) also talked how she had to address the issue of mental stillness and calmness with her client to allow for any subsequent physical restoration or intervention. It is a very vital concept to learn and to teach a client how the core of one's being remains unchanged inspite of any "violent illness or condition". Some experience this on their own as I think of book "Stroke of Insight" by Jill B Taylor and some need facilitation. As a clinician who is strengtheing her self-practice and learning more, I am eager to learn how to facilitate that with my clients. Are there some key things that can be kept in mind and introduced to the client early on in their rehabilitation (which can be brief 3-4 weeks for an inpatient setting in which I work)? Fortification of mind is vital to handle life better but it becomes all the more imperative after a challenging illness. The self-awareness and mindfulness that you mention would mean, acknowledging oue's fears at the present (does that mean not saying to the client that all will be better), one could chronicle those, be comfortable being with oneself (donot have to have TV run in background all the time), make healthy chages in lifestyle as warranted.......
I inch to know what all I should be aware of and offer from the wealth that is yoga as I work with my clients in rehab.....
Thank you for some thought provoking concepts.
Rashmi
In response to Dr Zwick's post
I obtained the referenced article and read about the concept of muscle elongation with prolonged sustained stretch. The 30 min duration was the key component which again is not new as that is the basis for splinting and other orthotic devices used in rehabilitation. The concept of therapeutic positioning stroke clients is also very grounded in management of stroke clients. This took be to another article by Sable and Gallagher, "Restorative Yoga"(OT Practice, Oct 2007). They discuss application of restorative yoga poses for reducing muscle tension, improving breathing efficicency, postural control, and for organization of muscle coordination which overall will help facilitate neuromuscular reeducation in stroke clients.
Any further thoughts are welcomed.
Thanks
Rashmi
I had a stroke in Oct. 2008 at the age of 45. It was completely unexpected and a total shock. I had been practicing yoga for many years before my stroke, so I was very happy when my health insurance company offered to cover the cost of a "gentle yoga" class close to my home. It has been wonderful. My stroke caused my left arm and leg to be temporarily paralyzed, but they are now just very numb. The yoga helps me stretch out my left side, decrease the numbness, and increase my flexibility. I am by far the youngest person in the yoga class, but everyone there seems to be dealing with some type of health issue and really benefits from the class. I would recommend yoga to anyone who has had a stroke, it has been particularly helpful with my balance.
hi rashmi
sorry I am kind of an email slacker and my laptop was "out getting fixed" but i eventually respond! you asked me how often, what kind of poses etc. I only go once a week and there is really only 1 pose where i hold on to a chair. we are just circling the ankles. the rest is bending from the hips standing or sitting, massaging the face, moving the head gently,; it is just gentle movement which right now is good for me. once in a while i try the triangle or warrior at home - its kind of modified as my left leg can't support me the same as right and it gets kind of painful or tiring.
I do want to share my experience with NIA with you however. NIA is a combination of dancing, martial arts and yoga done with all kinds of music. i did it for years before my stroke and was blessed that my teacher worked with me individualy for a year exploring my limits and abilities about a year after my stroke. she would modify movements for me yet keeping time to the music. and we did the best thing we could - my teacher started "Restorative NIA" and now we have a class where people with brain injuries can come and do NIA! I have to stop typing as my fingertips burn. go to Nia.com to find out more about NIA. and i will be back in touch soon! sincerely Anita
Anita,
Thank you for your response and effort. NIA is a new piece of knowledge for me.
YOU seem to be enjoying your yoga classes. Is it too early to state any improvement you feel as you just started yoga classes or may be not as you have been doing NIA for a while and you say that has elements of yoga too?
Control of arm and hand especally is so hard. Anything that you think has helped most with re-learning the use of arm?
Thank you
Rashmi
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POSTER BOARD S33: ENHANCING BALANCE, LOWER EXTREMITY FUNCTION, AND GAIT IN PEOPLE WITH PARKINSON'S DISEASE THROUGH YOGA EXERCISE.
Lee, Laura W. MD
American Journal of Physical Medicine & Rehabilitation. 85(3):284, March 2006.
[AAP Annual Meeting Abstracts: Abstracts of Scientific Papers and Posters Presented at the Annual Meeting of the Association of Academic Physiatrists: Daytona Beach, Florida March 2-4, 2006: POSTER BOARD PRESENTATIONS: Saturday, March 4, 2006]
AN: 00002060-200603000-00167.
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I guess I prefer Tai Chi rather than yoga because the movements are more likely to be successful. Here is my take on the corpse pose.
Failing at the corpse pose in yoga
The corpse pose, or Savasana in Sanskrit, is the most restful pose in yoga. It's the final pose used in most yoga classes, but can also be done on its own to facilitate meditation or relaxation. You lie on your back, legs slightly spread, arms slightly spread out.
This is supposed to be the easiest pose in all of yoga and I can't do it because my bicep and pectoral muscles are spastically contracting and pulling my arm up onto my lap.
My father has suffered a stroke. His left side has been affected. I want to know specific asanas and pranayama that can he of help to recover his mobility of limbs. please advice.
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