Friday Q & A: Broken Blood Vessels in the Eyes

Closed Eyes by Odilon Redon

Q: Today one of my students said that a couple of days ago she noticed a broken blood vessel in her left eye. This occurred the day after doing inversions in class. She asked me if I thought the inversion caused it. To be honest, I'm not sure, but I suspect it might have. She's been practicing yoga for 3 years and had done inversions before. This is the first time she got a broken blood vessel. Do you have any suggestions? Maybe you could point me towards an article you wrote on this topic. I also get concerned about students who get really blood shot eyes after inversions. Do you think this is a warning sign? Or a problem?

A: Let’s address the question of the broken blood vessel in the eye that showed up the day after inversions were done in class. The situation where a tiny blood vessel in the eye ruptures under the clear part of the eye (the conjunctiva) and causes an area of blood red to appear in the white part of the eye (sclera), either to the right or left of the colored part of the eye, is most commonly known as a subconjuctival hemorrhage. Usually, you don’t know it has happened until you look in the mirror. Because the area of trapped blood is so pronounced, people often worry something really bad has happened. It turns out this condition is not a problem and will usually resolve in one to two weeks. Why so long? Well, the conjunctiva does not reabsorb the blood very quickly, so it takes awhile for the blood to disappear. According to the Mayo Clinic, it is usually a harmless condition, sometimes without an obvious cause, but occasionally associated with a cough or sneeze that causes a blood vessel to break. No specific treatment is recommended, and, as I said already, it usually resolves in a few weeks.

Since most people don’t know they have it until they look in the mirror, usually there are no other symptoms. On occasion, some folks will notice a bit of a scratchy feeling over the surface of the eye. It should not affect your vision, cause any discharge from the eye or cause pain—great news! As to the underlying cause of the broken vessel, sometimes it is not known, but according to Mayo Clinic, any of the following could be a cause: violent coughing, powerful sneezing, heavy lifting, or vomiting. An eye injury such as roughly rubbing the eye, a severe eye infection or a trauma to the eye such as a foreign body in the eye more rarely could be the cause. People are at higher risk for developing a local eye bleed like this if they have diabetes, high blood pressure, blood-clotting disorder or are taking medications like blood thinners or aspirin.

Now, to our student who developed a subconjuctival hemorrhage. I’d certainly check in with them to see if they have any risk factors as listed above. But unless they have this recurring more than once, it is probably not a problem that needs to be further addressed. Could the inversion have lead to this? It could, especially if the student was not doing inversions regularly and was straining to go in, stay in, or come out of the inversions. The pressure that goes towards the head, and therefore the eyes, could mimic the pressure build up of heavy lifting (one of the causes of subconjuctival hemorrhage). In general, doing lots of warm ups that eventually lead to the full inversion may help to prepare the entire body system to work without overworking and prevent such bleeds from happening again.

As for the observations that other students sometimes are noted to have bloodshot eyes after inversions, this again could be a result of the increase in pressure and blood flow towards the eyes from the inverted position. And unless they have risk factors for not doing inversions, good preparation with longer Downward-Facing Dog poses and other milder inverted positions, before doing the full inversions, and not staying long in the full inversions if they are new to them, may reduce the likelihood of this to occur. And consider other reasons for having bloodshot eyes, such as smoking pot (yes, really).

—Baxter

recomended product suport by amazon

Opening Your Yoga Toolbox

by Nina

by Van Gogh

Did you know you have a your own personal box of yoga tools in your yoga room, your yoga corner, or that empty strip between the TV and the couch? And that when you’re experiencing some physical or emotional difficulty, or if you just want to work on your overall wellbeing, you can open up that toolbox, select a few tools and get to work?

Yes, it’s kind of like Christmas, so let’s open up the box and see what’s inside! Ooh, it’s very well organized. We’ve got three basic types of tools:

1. Physical health tools for body and brain
2. Stress management tools
3. Equanimity tools

Yes, your toolbox is very full! And before we can talk about how to use all those tools—we’ll be getting to that in future posts—it’s good idea to learn a little more about each of them. So let’s take a closer look….

Physical Health Tools

Although people tend to think of yoga poses as “just stretching,” the full asana practice is much more comprehensive. Weight-bearing poses strengthen muscles and bones, including those in upper and lower body, keeping us fit and helping to prevent osteoarthritis and osteoporosis. Balancing poses and flow yoga train us to be steady and agile on our feet, preventing falls and allowing us to move through the world with ease and self-confidence. Inverted poses lower blood pressure and improve circulation, benefitting physical as well as brain health. The stretching poses are invaluable as well, because being able to bend and reach and twist are essential for staying active and independent.

Since our toolbox is very organized, we’re going to divide the physical health tools into five categories:

Strength Poses and Practices. Maintaining muscle strength helps combat sarcopenia and maintains joint health. Maintaining bone strength helps combat osteopenia and osteoporosis. In general, maintaining strength allows you to be physically active and independent.  Classic examples include Warrior 2 and Downward-Facing Dog poses.

Flexibility Poses and Practices. Maintaining flexibility of both muscles and fascia preserves range of motion in the joints, fostering joint health and improving arthritis symptoms, and allows you to participate in a wide range of physical activities. Classic examples include Reclined Leg Stretch pose and Cow-Face pose.

Balance Poses and Practices. Maintaining the ability to balance is crucial for preventing falls, and enabling you to be physically active and independent. Classic examples include all wide-legged standing poses as well as balancing poses like Tree pose and Half Moon pose.

Agility Poses and Practices. Maintaining agility increases your reaction time in the real world, preventing injuries and allowing you to keep up with a wide range of physical activities. Classic examples include moving in and out of poses with your breath, as well as linked sequences of poses.

Circulation Poses and Practices. Improving circulation returns venous and lymphatic fluids to the heart, lowering blood pressure and improving heart health. Classic examples include inversions, such as Legs Up the Wall pose, and moving in and out of poses with the breath.

Baxter will be writing about these five different categories in the weeks to come so you can learn more about the essential poses in each category and how you can use them.

Stress Management Tools

Reducing stress can help prevent major age-related diseases, including heart disease, high blood pressure and diabetes. It helps prevent depression, anxiety, insomnia, obesity and digestive problems. Stress reduction also bolsters your immune system and reduces inflammation, which help promote overall health. Yoga’s stress management tools all provide you, in different ways, with the ability to switch your nervous system from Stress response (Fight or Flight mode) to Relaxation mode (Rest and Digest mode), thereby reducing your overall stress levels and allowing you to experience the benefits of conscious relaxation. In this category, we have six basic tools:

Meditation. This practice triggers the relaxation response through your focus on an object of meditation. Options include both seated and reclined meditation, with a mental focus of the breath or other physical sensations, mantra or sound, and visual imagery.

Breath Practices. These practices trigger the relaxation response either through providing a mental focus, or by slowing the breath or extending the exhalation. Breath practices can be performed either seated or reclined.

Restorative Yoga. These poses provide deep physical relaxation by supporting and relaxing your body, and can trigger the relaxation response if you practice them with a mental focus. Classic examples are Reclined Cobbler’s pose and Supported Child’s pose.

Supported Inversions. These poses use gravity to trigger the relaxation response through the mechanisms that control your blood pressure. Classic examples are Legs Up the Wall pose and Supported Bridge pose.

Savasana. This pose, in both plain and supported forms, provides deep physical relaxation for your body and can trigger the relaxation response if you practice it with a mental focus.

Guided Relaxation. Allows you to achieve both physical relaxation and reduce stress levels by guiding you through a deep physical relaxation experiencing and providing mental imagery that harnesses you to the present. 

Equanimity Tools

Physical poses and stress management practices help us to remain grounded, staving off anxiety and depression. And the wisdom of yoga teaches us to cultivate equanimity in the face of life’s challenges. Contentment—and even happiness—naturally arises when we make peace with what we cannot control and appreciate what we already have. 

Poses for Emotional Wellbeing. Yoga poses can affect the emotional body as profoundly as the physical body, and you can use them to move toward balance. Classic examples are backbends and moving with the breath for depression, active poses and forward bends for anxiety, inverted poses for general feelings of stress.

Meditation. Besides quieting your mind, these practices allow you to study your mind and slowly gain more control over it.

Mindfulness Practices. These practices harness you to the present moment, allowing you to let go of regrets about the past and worries about the future. Classic examples are using the asana practice as a moving meditation.

Yoga Philosophy. Studying yoga philosophy provides an alternative way of thinking about your life, allowing you to aim for equanimity rather constantly striving for “success.” Classic examples are The Bhagavad Gita and The Yoga Sutras. 

by Van Gogh

Want to Hammer a Nail?

Well, that covers the basics! And if you want to, you can put your toolbox away now for another time. But in my mind as I’ve been writing this, I have the image of showing a small child a box of household tools and explaining the name and purpose of each one. He or she would hardly be satisfied if you didn’t let them try at least hammering one nail! So if you’d like to try out one of these tools, well, just go ahead and do one pose or practice that we listed and observe what it’s doing for you.

recomended product suport by amazon

Building Unity Farm - Managing wood

Last weekend I drove to West Bridgewater, MA and picked up a 500 pound SuperSplitter  (J Model 6.5hp Honda engine).  It’s now installed in the wood processing area with 10 cords of wood to be split on one side and 10 cords of self-built storage racks on the other.

Here’s our wood management plan by tree species:

Eastern Red Cedar - we never cut cedar, which is a slow growing resinous tree that lives for 800 years.   We have hundreds of cedars on the farm, some of which were planted at the edges of pastures in the 1800’s.   Cedar waxwings eat the berries and spread the seeds.   As our Revolutionary War era pastures returned to woodlands, the cedars were crowded out and shaded, weakening them.   Hurricane Sandy knocked over several old cedars and we split the fast burning wood to use as fire starters, moth repellant, and incense.

Red Oak - Hurricane Sandy damaged an enormous red oak on the southwest corner of the farm.   We cut it down to ensure a controlled fall and now have thousands of pounds of red oak to split.   I prefer white oak which is easier to split and faster to dry into firewood, but after 2 years of aging, red oak supports hot, long lasting fires.

White Oak - when we cleared land for our orchard, we harvested over 1000 linear feet of white oak, which I cut into 4 foot logs for Shitake growing.   There are a few thousand pounds of logs too heavy for mushroom farming so I’ll process those with the new wood splitter.

Maple - The largest tree on the property is an enormous maple (6 foot diameter trunk) that is near end of life.  We have a large number of birds that nest in old trees, so we’ve cut off the branches and left a snag for wildlife.   The photo above is splitting some of the maple branches.

Ash - Dozens of large ash trees have fallen on the farm over the past few years due to the Emerald Ash Borer.   Ash is an amazing wood since it burns without any aging.   We’ve cut up all the fallen ash and I’m in the process of splitting it with the new splitter.

Black Birch - In a particularly violent winter storm (we’ve had 15 storms this winter) a large black birch with shallow roots fell into one of our paddock fences.    We have a few thousand pounds of black birch ready to split - it smells like root beer (birch beer) when cut.

Poplar - poplar wood is soft, burns poorly, and smells like glue.    Poplar grows very fast and falls frequently.  We process all of our fallen poplar into oyster mushroom logs or chips for the trails.

My upcoming wood management projects include:

Splitting the fallen cedar, red oak, white oak, maple, ash and birch then stacking firewood into 20 wood racks.

Collecting old fallen poplar (many tons to move with the Terex compact front loader) and chipping it into 5 strategically placed piles around the property for spreading on the mile of trails.

Creating a new mushroom farming area from fresh fallen poplar

Cutting new forest paths to the mushroom farming areas so that I can move logs around with the Terex.

Clearing fallen branches from the trails for kindling

There is still 2 feet of frozen snow and ice crust on the ground, but I’ve been able to dig out the maple and ash logs that I cut before Snow-mageddon.   The new splitter, which is flywheel-based, does not have a delay to refill a hydraulic piston.   Thus far, I’ve been able to split 1 cord an hour instead of 1 cord per weekend!

I look forward to the wood management weekends ahead as soon as we have a thaw.   It was 3 degrees F this morning while I was shoveling manure.   Managing anything on a farm at 3 degrees F is challenging.

recomended product suport by amazon

Chronic Stress Can Damage Your Brain

by Nina 

Opening Peas by Melina Meza

"Stress can damage the brain. The hormones it releases can change the way nerves fire, and send circuits into a dangerous feedback loop, leaving us vulnerable to anxiety, depression and post-traumatic stress disorder.” — Geoffrey Mohan, LA Times

One of my new areas of interest is brain health. Yes, not too surprisingly, I’d like to keep my brain—along with my body—healthy as I age (as I’m sure you all do, too). And one thing I’ve been noticing lately in my research is that chronic stress is as bad for the brain as it is for the body. In a way, that makes sense because really your brain is just another organ in your body, and we all know that chronic stress takes a toll on other organs, such as your heart and your digestive system. But I was fascinated to read recently in Stress matters to brain's white matter that neuroscientists at the University of California found evidence that cortisol, one of the stress hormones, trips a switch in stem cells in the brain, causing them to produce white matter cells that can change the way circuits are connected in the brain.

In a study published in Nature, Stress and glucocorticoids promote oligodendrogenesis in the adult hippocampus, researchers examined stem cells in the brain’s hippocampus. (The hippocampus plays an important role in the consolidation of information from short-term to long-term memory and spatial navigation. And in Alzheimer’s disease, the hippocampus is one of the first regions of the brain to suffer damage.) Under normal circumstances, these stems cells in the hippocampus form new neurons or glia, a type of white matter. But after examining the brains of mice that were chronically stressed out (yes, they’re stressing out those poor mice again), the researchers discovered that the stress hormone corticosterone (the rodent equivalent of cortisol in humans) causes the stem cells produce instead an abundance of oligodendrocytes. The LA Times quoted Daniela Kaufer, lead investigator of the study:

“Usually the brain doesn’t make much oligodendrocytes in adulthood from those neural stem cells. But under stress, all of a sudden, you discover they are making those cells.” 

She observed that moderate stress, such as that produced by studying for an exam or competing in the Olympic Games, can build stronger circuitry and a more resilient brain. But acute, prolonged stress can wreak havoc.

So scientists are now actually finding specific evidence—and understanding the exact mechanisms at work—of how chronic stress can actually damage brain. We’d all like to avoid that, I’m sure. Of course, chronic stress can also cause high blood pressure, which leads to strokes, also damaging—sometimes very seriously—the brain. In fact, my father suffered in the later part of his life from stroke-related dementia, so I’ve seen it up close.

If you haven’t already incorporated some yoga stress management techniques into your daily life, take a look at one of my early posts The Relaxation Response and Yoga, which gives an overview of the many options that yoga provides. There are so many choices you’re sure to find something you enjoy and that you can practice on a regular basis.

P.S. After my post on Of Mice and Men, are you wondering how the scientists stressed out their test subjects? According to the LA Times, the researchers stressed out the mice by either immobilizing them in a straitjacket for three hours a day, seven days a week, or injecting them with corticosterone. Tiny straightjackets for mice? I’m not so sure what I think of that.

recomended product suport by amazon

Social, Mobile, Analytics, and Cloud

On Monday at HIMSS, I signed my new book, Life as a Heathcare CIO for 300 folks at HIMSS.   During the rest of the day I met with numerous companies, leaders, and fellow IT professionals.   The theme I heard frequently was the need for care management/population health applications based on data acquisition, normalization, mining, and workflow.   Common characteristics of such applications included social networking features to gather data from patients/families/providers, a mobile component, a predictive analytics component, and cloud hosting.

I had no idea that the major consulting companies and analysts  have  already coined the SMAC acronym for this nexus of ideas (social, mobile, analytics, cloud)

As I walked the HIMSS floor, some of the care management applications I saw were real, developed in platforms like Salesforce and PegaSystems.   Others were “deployed” in Powerpoint, which is a powerful development language used by marketing departments to quickly author software :-)

As Accountable Care Organizations focus on continuous wellness rather than episodic sickness, the market for new tools will grow exponentially.    We have to be careful that social, mobile, analytics, and cloud (SMAC) does not become social, cloud, analytics and mobile (SCAM).

Here are few characteristics to look for in real care management/population health software

1.  Cohort identification - how can patients be enrolled in disease management and care management programs?  A drag and drop interface with concepts such as problems, medications, allergies, labs, and demographics should be available to specify cohort selection criteria.  Ideally, natural language processing will be available for cohort identification based on free text notes.

2.  Rules authoring - once cohorts are identified, there are likely to be protocols and guidelines that enumerate tasks to be done, gaps in care to be filled, and reminders to be sent to providers, payers, and patients.   The application should support user definable rules creation.

3.  Workflow - non-physician extenders are likely to use the application to ensure tasks are completed and to monitor patient progress.  Dashboards and automated "to do" lists should be available.

4.  Alerts  -  a change in patient status, based on patient self report or diagnostic data should result in an alert to the care manager, appointment scheduler and other care team members, triggering interventions such as home care visits.

5.  Patient Generated Data - often data about patient health status/outcomes are  best provided by
patients and families themselves.   Information such as activities of daily living, pain scores, mood, and medication compliance are not easily found in provider entered EHR data.    Interfaces to home care devices, mobile apps, and patient portals should be part of the care management suite.

Full featured care management software is a foundational strategic requirement for accountable care organizations.

Once we finish Meaningful Use Stage 2, the HIPAA Omnibus Rule, and ICD-10, we’re all likely to turn our attention to care management/population health as part of our Affordable Care Act implementation.

recomended product suport by amazon

Tax-Prep Neck (Neck Pain, Part 3)

by Baxter

Yes, it’s that time of year in the USA. We reluctantly sit down at our desks to do our taxes. And if you are like me, once I get cooking, I tend to not want to stop until I get as much of this thankless job done as I can. So, two weekends ago, I got into this annual ritual once again. And about an hour into it, looking down at my checkbook registry, highlighting business expenses and creating lists of all kinds of things our friends at the IRS want to see on our forms, I began to notice stiffness and pain creeping into my neck, and sensed fatigue in my neck muscles. Despite my regular yoga practice, gym workouts and general mindfulness about my overall posture during most days, I was still having neck pain! What gives?!

As many of you have probably also noticed, when you do an activity like tax prep, or the first time you garden each spring, or unexpectedly have to get under the sink to try a little home-fix, your body can actually respond with pain, soreness, and stiffness, despite being in overall “good shape.” With me and my tax prep, I was suddenly asking my body to hold or assume a position beyond the time that my other activities might have prepared me for. So, it really should be no surprise that this might challenge my body. And my body appropriately sounded its early warning system, that is, pain. Fortunately, I decided to listen to the warning sign and got up and did some simple yoga poses for a few minutes until I sensed that my neck musculature, soft tissues and bones were releasing their tension and the pain subsided and disappeared, allowing me to return to my desk and continue on with my task at hand.

For those of you who sit at desks all day long, taking breaks like this can be challenging—you’re often in the groove and getting a lot done, and the mind might decide to ignore the body’s signal that it needs some attention. I see the results of this choice in both my regular evening classes and in my weekly Back Care class, when my students arrive complaining of the stiffness and pain in their necks, There are lots of causes of neck pain (see A (Literal) Pain in the Neck). And I have even given you some appropriate practices to address neck pain (see Neck Muscle Strain and Spasm).

But today's post is mostly concerned with stiffness and pain that is a result of neck muscle overuse and fatigue I want to address what to do in the home office or at work where you might not have much time to address the neck symptoms and/or can’t easily get down on the floor, but you want to do a brief practice in the moment. Some of the poses I will mention today can be found in greater detail in other posts, such at the Office practice and the chair practices, so search out the ones that sound most interesting to you to get more details on your choices.

Tax-Prep Neck Sequence

At first sign of neck pain or stiffness, stand next to your desk in Mountain Pose or maybe even go outside (I stepped just outside my front door and did my standing work in the sunshine—do it if you can!)

In Mountain pose, practice a Dynamic Arms Overhead sequence, inhaling both arms forward and overhead, then exhaling your arms forward and down to your sides, repeating for a minimum of 6 breaths. This practice addresses the tendency to round the upper back (into kyphosis) at your desk, and the fact that desk work never or rarely involves moving the arms overhead. And inhaling your arms overhead brings your spine into a gentle standing back bend, the opposite shape you spine usually in at your desk!

From Mountain pose, inhale your arms out to your sides and then up overhead. Then, exhale and side bend your chest, head and arms over a bit to the right, inhale back to center, exhale and side bend to the left, inhale back to center, and finally exhale your arms out to the side and down. Repeat this sequence a few times, alternating the starting side-bend direction every other round. Releasing tension in the rib cage area can have a direct benefit for the neck and head area.

From Mountain pose, inhale your arms forward and up, and, bending your knees a bit, exhale into an easy Standing Forward Bend (Uttanasana), allowing your head to release with gravity. Then inhale as you bring your arms up overhead and exhale as you return to Mountain pose. Repeat five more times, and on the last time, stay in the forward bend for a few breaths, focusing on releasing your head and neck as fully into the pull of gravity as possible. In this pose, you are utilizing gravity to provide some passive traction for your neck muscles, fascia and bones to regain their full and relaxed length.

The rest of the sequence can be done standing or sitting. Do the neck movements described in Neck Muscle Strain and Spasm), which include the Owl turns and the Curious Dog Tips, moving in and out of those shapes with your breath.

If you feel tightness in the space between your shoulder blades in addition to neck symptoms, do Eagle pose arms (see Standing Shoulder Stretches), holding the position for 6-10 breaths while reminding yourself to relax the neck muscles at the same time. I find lots of practitioners are unaware of how tense they allow their neck to be in this pose without a gentle reminder otherwise.

Cow-Face Pose arms (see Standing Shoulder Stretches) is another great pose to release the shoulder girdle and tricep muscles, and influences the neck as well. I recommend holding for 6-10 breaths initially, but gradually working towards 90 seconds to create longer lasting changes to the muscle/fascial length of this area.

Finish with at least one minute of gentle breath awareness with the inner lift of the spine, the Prime directive, in place. You might add in the mantra on the exhalation of “I am taking good care of my neck” as a reminder of how you want the remainder of your work time to go.

You can do all of these poses if time permits, or choose just a few that seem to best address your unique circumstances. Also, I have gotten better and better at setting the timer on my smart phone at 30- to 60-minute intervals to remind me to get up and do my yoga sequences. And guess what? When I do this my neck doesn’t hurt. So you might try this timer approach.

I should mention the potential positive aspects of reviewing your year of income as you do your taxes: it’s an opportunity to acknowledge gratitude to all of the people you interacted with and worked with and worked for as you made your living the last year. For me, this helps foster my sense of community, which, as we have mentioned before, seems to be a key factor in lengthening the “health span” of a good, long life!

Upcoming Workshop: Learn more about how yoga practices can promote a healthier neck in Baxter’s Bay Area workshop this coming weekend:
 
March 1st, 2014, 2-5pm

Uncranking Those Cranky Necks

Mountain Yoga Studio

Montclair Neighborhood, 
Oakland, CA

recomended product suport by amazon

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.” 

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.

recomended product suport by amazon

The Voluntary 2015 Edition Electronic Health Record Certification Criteria

There's nothing like a crisp New England winter evening, a roaring fire, a cup of cider, and a 242 page Notice of Proposed Rulemaking to fill your Friday night.

I've summarized the preamble and all 50 criteria to save you time as you consider the proposals during the 60 day comment period.    Note that no vendor needs to implement 2015 criteria and no provider needs to adopt 2015 certified software, hence the term voluntary.  In many ways, this document is meant to signal what might be included in the 2017 edition that supports Meaningful Use Stage 3.

Roughly 60% of the 2014 Edition EHR certification criteria are unchanged in the 2015 Edition. The remaining certification criteria proposals for the 2015 Edition fall into four general categories: clarifications, standards updates, revised approaches, and new certification criteria proposals.

As with the Meaningful Use Stage 3 proposals, I'll pose questions, not to be judgmental but to get us all thinking about the scope, timing, and purpose of the certification program over the next several years.

The preamble highlights several big ideas -  elimination of the 'complete EHR' designation, separation of content/transport certification criteria, adoption of new standards, more frequent certification rule making, and the need for 2017 edition proposal feedback.

Complete EHR was a very confusing concept to me that led many to buy single vendor systems as the "safest" option instead of assembling modules.   I applaud the idea of eliminating terms like Complete EHR and Optional Certification criteria.   Each certification criterion should stand alone and during attestation you should "fill your shopping cart" with only the certified modules you need.

Separating the content and transport certification criteria is a good thing.  The 2014 Edition which linked the two concepts proved to be very problematic in Massachusetts where the state HIE performs all of the Direct and XDR functions we need, so no EHR requires transport capabilities.   Yet because EHRs had to be certified to do both content and transport interoperability, extra work and expense was incurred.

The logic behind more frequent certification rules is that it enables "bug fixes" and more rapid adoption of standards.    However, we should ask the question - even with a voluntary program, just how fast can we develop software, install upgrades, revise workflow, educate clinicians, and support new software versions?   My experience is that changes of this nature take 3 years from regulation to attestation, at a minimum.

Here's my advice while reading the 50 certification criteria:

Focus on the fixes.  There were many challenging issues in the 2014 Edition.  The 2015 Edition fixes several of them.  Even if something looks more complex (like separating content and transport criteria),  it is simpler, and provides more market flexibility.

Identify the burden reduction.  Vendors of "non-MU Eligible"  software such as long term post acute care no longer need to develop "MU-required" functionality such as measure calculation to get certified.

Recognize that about 30% of the document is requesting comments for the 2017 Edition, not specifying 2015 requirements.

The proposals are just that - proposals.  It's hard to know how many will be incorporated into the final rule.  Much depends on feedback from stakeholders.   Certainly the Standards Committee and its Implementation Workgroup will offer substantial feedback.

Although some of the proposals do not seem like the highest priorities, there is someone inside or outside government who believes each proposal is important to healthcare.

If you have questions about intent, re-read the pre-amble.   It's well written and provides a context for the 50 proposals.

Here are the actual certification criteria

1.  Computerized Provider Order Entry
The functional requirement for medication/lab/rad ordering is split into 3 modular criteria, enabling novel functionality like mobile medication ordering to reside in its own application.   Since lab ordering standards are not consistently implemented, this proposal suggests using the S&I framework Laboratory Orders Initiative Draft Standards for Trial Use which have been approved by HL7 ballot.

2.  Drug-drug, drug-allergy interaction checks
The proposal includes a provision to consider tracking user actions i.e. what advice was ignored and what were the consequences when advice was ignored?    The interesting debate here is what to track and what to do with the tracking data.   This could be burdensome and have limited customer demand.

3.  Demographics
The proposal includes a new standard for recording preferred language that focuses more on spoken rather than written language.   It also requires that EHR technology must enable a user to electronically record, change, and access the date of death and the preliminary cause of death.

4.  Vital signs, body mass index, and growth charts
No change, although there is a discussion of requiring controlled vocabularies such as UCUM for units of measure in the EHR and in transmission of summary records.

5.  Problem list
No change

6.  Medication list
No change

7.  Medication allergy list
No change

8. Clinical decision support
The proposal adds a requirement to demonstrate decision support based on specific demographic requirements such as gender or date of birth.   It also simplifies the Infobutton demonstration criteria to better align with the capabilities of the standard.  Finally, the proposal would require importing of externally authored decision support rules and a query/response interface to remote knowledge resources.   We should debate the complexity, standards maturity, and appropriate initial use cases to demonstrate this functionality.

9. Electronic notes
The proposal requires search for information across separate notes within the EHR i.e. a Google-like function for structured and unstructured data.   It could be very complex.

10. Drug formulary checks
No change

11. Smoking status
No change

12.  Image results
No change

13. Family health history
The proposal requires the use of the HL7 Pedigree standard, eliminating the option to use SNOMED-CT for family history.

14.  Patient list creation
As with decision support, patient list functionality  must be able to filter based-on specific demographic requirements such as gender or date of birth.

15.  Patient-specific education resources
As with decision support, Infobutton requirements have been simplified.   There is an odd provision in this section requiring the use of Infobutton and an alternative to Infobutton.  That should be debated.

16.  Inpatient setting only – electronic medication administration record
No change

17.  Inpatient setting only – advance directives
No change

18.  Implantable Device List
This proposal requires the EHR to record and display a unique device identifier (UDI) to facilitate the widespread capture and use of UDI data to prevent device-related medical errors, improve the ability of hospitals and clinicians to respond to device recalls and device-related patient safety information.  UDI must also be incorporated into the CCDA interoperable data sets for

170.315(b)(1) – Transitions of care.
170.315(b)(6) – Data portability.
170.315(e)(1) – View, download, and transmit to third party.
170.315(e)(2) – Clinical summary.

The FDA work on UDI is excellent.  We should debate the role of the EHR for recording UDI data versus other alternatives such as registries.

19.  Transitions of care
As described in the preamble, content and transport are split into two certification criteria.  The best part of this revision is that it aligns certification with the notion that EHRs may communicate with regional or third party HISPs without the need for every EHR to be its own HISP.

Updated standards are used for transition of care content.

Rather than require healthcare information exchange with a different vendor's EHR (very hard to measure), the certification criteria will be the EHR's capability to import hundreds of different CCDAs with at least 95% success.   That could be very burdensome.

The proposal also includes a requirement that the EHR support appropriate demographic fields for patient matching - name, gender, date of birth, address etc.

20. Clinical information reconciliation and incorporation
The term "incorporation" can be confusing so this proposal formally defines CCDA import as reconciliation of externally provided summaries including reconciliation of medications, medication allergies, and problems.

21.  Electronic prescribing
No change

22.  Incorporate laboratory tests and values/results
The proposal includes updated standards - HL7 Version 2.5.1 Implementation Guide: Standards and Interoperability Framework Laboratory Results Interface, Release 1 (US Realm) (S&I Framework LRI) with Errata

23.  Inpatient setting only – transmission of electronic laboratory tests and values/results to ambulatory providers
The proposal includes the same updated HL7 Version 2.51 LRI standard.

24. Data portability
The proposal includes an updated standard - Consolidated CDA Draft Standard for Trial Use, Release 2.0 plus a requirement that the Universal Device Identifier data be exportable.

25.  Clinical quality measures – capture and export
No change

26.  Clinical quality measures – import and calculate
No change

27. Clinical quality measures (CQM) – patient population filtering
This proposal requires filtering of CQMs by patient population characteristics such as
Practice site and address, Tax Identification Number (TIN), National Provider Identifier (NPI),Diagnosis (e.g., by SNOMED CT code), Primary and secondary health insurance, including identification of Medicare and Medicaid dual eligibles, Demographics including age, sex, preferred language, education level, and socioeconomic status.   We need to take a careful look at the burden of all the various quality related measurement provisions of Meaningful Use, as they are already overwhelming.

28.  Authentication, access control, and authorization
No change, but there is a discussion of the future need for two factor authentication in support of controlled substance e-prescribing and possibly remote access.

29.  Auditable events and tamper-resistance
The proposal suggests that disabling audit logs should be prohibited.  I'm not aware of any EHR which enables audit logs to be disabled.

30.  Audit report
No change

31.  Electronic Health Record Protections
§ 170.315(d)(4) (Amendments)
§ 170.315(d)(5) (Automatic Log-Off)
§ 170.315(d)(6) (Emergency access)
§ 170.315(d)(7) (End-User Device Encryption)
§ 170.315(d)(8) (Integrity)
No change

32.  Accounting of Disclosures
No change

33. View, Download, and Transmit to Third Party
A patient must be able to download an ambulatory or inpatient summary in only the human readable format if they just want that, in only the Consolidated CDA format if they just want that, or in both formats if they want both.

As with other interoperability criteria, this proposal decouples transport and content certification.    I've mentioned in previous blogs that this is important, since the ecosystem of infrastructure and applications to support patient transmit is still evolving.

This proposal focuses on a patient’s ability to choose the destination to whom they want to send their health information and the outcome, rather than the specific mechanism of transport.

The proposal includes more rigorous accessibility guidelines - WCAG 2.0 Level AA

34.  Ambulatory setting only – clinical summary
The proposal includes CVX codes for immunizations, and requires the updated Consolidated CDA version (Draft Standard for Trial Use, Release 2.0)

35.  Ambulatory setting only – secure messaging
No change

36.  Immunization information
No change

37.  Transmission to immunization registries
Updated standards

38.  Transmission to public health agencies – syndromic surveillance
The proposal expands possible standards to include HL7 CDA and QRDA III for ambulatory users only

40.  Inpatient setting only – Transmission of reportable laboratory tests and values/results
The proposal includes updated HL7 2.51 standards

41. Ambulatory setting only – cancer case information
The proposal decouples content and transport for delivery of cancer case information to registries.

42.  Ambulatory setting only – transmission to cancer registries
The proposal includes updated standards

43. Automated numerator recording
No change

44. Automated measure calculation
No change

45.  Safety-Enhanced Design/Quality Management System
No change

46. Non-percentage-based measures report
Since some of the certification criteria are not percentages, this proposal requires that an EHR be capable of electronically generating a report that shows a user has interacted with the technology capability associated with a non-percentage-based MU measure during an EHR reporting period.    This could be very burdensome and needs to be reviewed.

47. Transmit – Applicability Statement for Secure Health Transport
This proposal certifies only the Direct protocol

48.  Transmit – Applicability Statement for Secure Health Transport and XDR/XDM for Direct Messaging
This proposal certifies Direct and XDR/XDM

49.   Transmit – SOAP Transport and Security Specification and XDR/XDM for Direct
This proposal certifies SOAP and XDR/XDM

50.  Transmit – Applicability Statement for Secure Health Transport and Delivery Notification in Direct
This proposal certifies Direct and end to end result delivery notification

These last 4 criteria may seem confusing, but their intent is to enable EHR vendors to certify as much or as little transport functionality as they want so that an EHR can be a modular component in an HIE/HISP ecosystem.

My takeaways from the 242 pages

1.  60% of the criteria are the same. 40% are modified/new.   Many of the modifications are to correct issues in the 2014 Edition and are reasonable.  Some of the new criteria could be very burdensome.   We need to debate the collective burden of the Meaningful Use program in the context of ICD10, ACA and the HIPAA Omnibus rule burdens.    Each individual project may be reasonable but the collection of all the projects is not.

2.  ONC is proposing more frequent certification NPRMs.   We should debate if increased  frequency is a good or bad thing given the realities of implementation and competing projects.

3.  Overall we should debate the role of certification going forward.  Should government provide a list of EHR functional priorities or should that be left to providers, patients, and developers?   How prescriptive should government be i.e. roads should be 30 feet wide, but drive whatever you want versus your car must have 2 headlights, a catalytic converter, seat belts, and 4 tires versus you must drive a SUV.

4.  Major new concepts in the document to review include
HQMF quality measure definition as a 2017 criteria (import quality measures automatically)
HealtheDecisions for decision support rule importing/knowledge access in 2015
Recording Universal Device Identifier for implants
QRDA II (a new format for quality reporting) as a 2017 criteria
Stratified quality reporting in 2015
Testing CCDA receiving ability with hundreds of  CCDAs in certification,  importing 95% successfully
Searching across the entire patient record
Tracking non-percentage based MU measures in a report
Upgrading lab interface standards including orders
Two factor authentication for e-Prescribing and remote access

5.  Although the fixes are much appreciated, are they too late since most vendors in the Meaningful Use program have already completed the work of certification with the 2014 Edition, despite its flaws?

As with the Meaningful Use Stage 3 proposals, let the debate begin!

recomended product suport by amazon