Yoga After Heart Surgery for Stent Placement

by Baxter

Back in the late 60s and early 70s, a new surgical treatment for blocked heart blood vessels was being perfected. Known as coronary artery bypass grafting, it allowed doctors to work around the heart’s own blood vessels that supply the muscle of the heart with oxygen and nutrition when they became dangerously plugged with plaque buildup. Patients that previously would have, most likely, suffered severe or life-ending heart attacks were now being surgically repaired and at least temporarily “cured” of their heart blockages. I say temporarily because doctors like Dean Ornish, MD, noticed that many of these patients who had undergone open-heart surgery would return several years later with new blockages in their new plumbing! Most likely, this was due to the fact that they had not changed their lifestyle and dietary habits. 

As early as 1977, cardiologists started trying to treat the blockages in the heart blood vessels without having to crack the chest open, instead threading a catheter into a large blood vessel in the groin area and guiding it up to the heart and into an individual heart blood vessel. Once at the narrowing area of the blood vessel threatening the patient’s heart, a small mesh scaffold, called a “stent,” was slipped into place and gently expanded to reopen the narrowing. This stent was then left in place. 

All this history gets personal for both Nina and me, as we both have had loved ones undergo stent placement for coronary heart disease in the past year. In my case, my family member had just celebrated his 50th birthday, and with little prior warning or symptoms, had a sudden cardiac event at home that required CPR and electric shock to the chest by the EMTs to restart the heartbeat again. Evaluation at the hospital immediately afterwards showed one heart vessel with a blockage and a stent was put in place right away. Follow-up tests showed no permanent damage to the heart muscle from this heart attack—thank goodness!

It has been found that patients who go through “cardiac rehabilitation” programs following stent placement do better down the road than those that don’t. Cardiac rehab involves progressive aerobic activity on treadmill and stationary bikes while having the heart rhythm monitored, for 30 minutes 3 times a week for 3 weeks, then bumped up to 45minutes, 3 times a week for 3 more weeks. In my family member’s situation, he had been very physically active prior to his event, swimming and golfing regularly, and he was anxious to be able to return to those activities. If yoga had been his thing, I suspect that same desire would have been there. So, what are the recommendations about “return to activity” that could guide you as a yogi if you have to have a stent placed? The NIH has the following post-stent recommendations:

“After a stent procedure, [because of the risk of blood clots causing your open vessel to close,] your doctor will likely recommend that you take aspirin and other anticlotting medicines. Patients are told to avoid vigorous exercise and heavy lifting for a short time after the stent procedure. Your doctor will let you know when you can go back to your normal activities. … However, stents aren't a cure for atherosclerosis or its risk factors. Lifestyle changes may include changing your diet, quitting smoking, being physically active, losing weight, and reducing stress. You also should take all medicines as your doctor prescribes. Your doctor may suggest taking statins, which are medicines that lower blood cholesterol levels.”

Interestingly, there aren’t many other warnings I could find about returning to full activities, such as yoga, and no specific warnings about avoiding certain positions, including inverted yoga poses. In fact, a student of mine had his first of four stents placed for angina, or heart pain, starting at age 67 in 2000. He started doing yoga in 2003, which included regularly practicing Shoulderstand (Sarvangasana) at the wall in his new home yoga practice. He has continued to include it since then. He felt pretty certain he had discussed doing yoga with his family doctor at the time, as well as his heart doctor, and was not given any specific restrictions or warnings about yoga in general. 

I would not suggest that this means you should start a vigorous yoga practice that includes a lot a challenging inversions, but would instead suggest a gradual introduction of yoga over the course of time, just as the cardiac rehab is gradually advanced while monitoring for worrisome symptoms. And certainly engage in a conversation with your heart doctor about their views on the safety of your desired yoga program. Also, keep in mind that even a gentle yoga practice, like the one used in the Ornish Heart studies, has been shown to have powerful effects on long term heart health. So you likely have a wide range of options as to the kind of yoga practice you might restart or start for the first time if you find yourself confronted with a new diagnosis of coronary heart disease. If any of our readers have been given different advice by their docs, please write to us about it.

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Savasana: Silent or Not?

by Baxter

One of our readers recently sent us this topic idea for a post:

I am usually ready to cry in class when the teacher insists on talking throughout Savasana. I had one class where the teacher literally droned about how important silence was for >10 minutes. If silence was so important, why couldn’t she have given us some?

There is more to this question than meets the eye, or the ear in this case! Some of the challenge is that modern Savasana (Corpse pose) is taught is so many ways by so many teachers, and different modern yoga traditions often have different recommendations on the best way to do it and what the purpose or focus should be.

One option is that Savasana is just another body position in which you can meditate. If so, getting yourself or your students into a comfortable Savasana and then letting yourself or your students use whichever the meditation technique they are presently practicing for the remainder of the Savasana time is all that is required. So there would be the potential for the room to be quiet for a good part of the pose (that may not be the case with your mind, of course, but that is what you are working on!). In a mixed level class, I feel as a teacher that I may need to talk for a few minutes on how to enter the meditative practice, especially if I have newer students in class.

There is another option of Savasana being used for a guided mediation, such as a simple body scan (see Audio Tracks for a free recording) or a more elaborate yoga nidra practice (see Audio Tracks for recording of a short version), in which the practitioner is guided by the voice of teacher for most of the time in the pose. I find for students with very active minds who get more busyness in their minds when the room is completely quiet, these guided meditations in Savasana actually quiet their minds and bodies more effectively than a silent personal meditation.

In some traditions, Savasana is also used as a spacer between more active poses, where the practitioner goes into Savasana between every other pose done in a particular practice. That is a lot of Savasanas! But in these classes, it is only held for a minute or so, and can be an opportunity to reflect on the effects of the previous pose done or just to rest.

Historically, Savasana, translated as “Corpse” pose or “Death” pose, was likely nothing like it is today. After all, who in their right mind would name a pose after death if they wanted to appeal to a modern audience! This is probably why a lot of teachers rarely mention the real translation and instead call it “Relaxation” pose. In has book Original Yoga Richard Rosen notes:

“We know for sure that some schools of Hatha [Yoga] encouraged members to frequent graveyards and to meditate there on the transience of life while perched on a corpse no less—quite literally a Shavasana, “corpse” seat.” 

Why on earth, you may ask yourself, would they want to do something like that? Richard explains:

“Death, too, had a different meaning for these men; it stood not for the much-feared end of worldly life, but for the death of their limited ego identity and their final release from existential suffering.”

Richard has more to say about this important pose in his book, and I highly recommend the book for those of you who don’t already have it!

So, to our reader, I’d encourage her to find a teacher that offers the Savasana experience she is looking for, or push the boundaries of her understanding of Savasana and try out many types of Savasana with an open, curious mind. 

For more on Savasana, see Savasana (Corpse Pose) for instructions on how to practice Savasana, Savasana (Corpse Pose) Variations for information on supported versions of the pose, and Friday Q&A: Savasana vs. Seated Meditation for a conversation between Nina and Timothy McCall about the difference between meditating in Savasana vs. seated meditation. 

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7 Tips for Mastering a Yoga Pose by Teaching It to a Newbie

by Baxter

Photo by Melina Meza

So you want to master some of your beginning level yoga poses? Trying to teach someone else how to do one of your favorites might be just the ticket! That's because I believe a big factor in learning a pose is that the “teacher” becomes very clear on what the steps are in doing the pose that they have been following in their own minds from what they themselves had been taught. These inner instructions that have been gleaned sometimes over years of study —often from multiple teachers—may initially seem automatic. But when you have to demonstrate or verbalize what it takes to do a pose to someone else, you become more conscious of the details and complexities of the pose, which leads to a greater sense of mastery. 

So here’s a list of tips to help you learn to teach a yoga pose to a beginner, whether that is in an official private lesson or just some friend or family member you’ve convinced/coerced into helping you by being your “student.”

Before trying to teach the pose to someone else, guide yourself into the pose and out, noticing what your “inner” teacher is telling you to do and how things are feeling inside. This will help you begin to get clear on the essential things you already know about your pose.

Tips for Teaching a Yoga Pose to a Newbie

1. Set your mats up parallel to one another. Ask your student to mirror what you do as precisely as they can, as you demonstrate the pose. Think of this as an adult version of Monkey See, Monkey Do! (Mirroring does require that, for asymmetrical poses, you do the left side while they do the right and right side while they do the left.)
2. As you get a sense of how well your student is copying you, can you use one hand to point out on your body an area that the student may not be noticing and exaggerate the position or movement they still need to find.
3. Don’t keep your student too long in any pose—newbies tire quickly! Instead, repeat the pose for short intervals several times.
4. Think about the top-three key actions or movements that you have learned to do in the pose and verbally share those with the student while you mirror it. Repeat the words several times, as sometimes it will take a while for the info to settle in.
5. Try entering and exiting from your pose using your breath, without hanging out in the pose. For example, with Triangle pose (Trikonasana), bring your arms up to parallel with the floor as you inhale, tip into the pose on your exhale, inhale back up to arms out to sides, and lower your arms to your sides on the exhale. This is a great way to warm your student up for the pose and bring them into greater connection to their breathing!
6. Some people are more tactile learners, so if your student gives you permission, you might use touch to gently guide the person deeper into the pose you are sharing with them. Or use a prop to assist you, such as a strap around the upper thighs in Downward-Facing Dog pose to pull the thighbones away from the hands, which will teach them to lengthen the spine.
7. Since mastering a yoga pose is as much about the internal “feeling experience” as it is the external alignment, you might describe to your student what internal sensations you are feeling in different areas of your body, and then ask them to notice and describe what they are feeling to you. It might be completely different because, of course, no two people are exactly the same—that is okay!

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Multiple Sclerosis (MS) and Yoga: New Study Results!

by Baxter

Eric Small, Iyengar Yoga Teacher*

One of the four pillars of our Yoga for Healthy Aging program is focused on improving balance and we have many past posts  about how yoga can be beneficial in fostering better balance. I have also written previously about one particular health condition that can dramatically affect a person’s balance, Multiple Sclerosis (MS). I dedicated a Friday Q&A to it a while back and would highly recommend you review that post Friday Q&A: Multiple Sclerosis.

It turns out that most of the experience of applying yoga to MS symptoms has not been organized into formal scientific studies. Therefore, we call this kind of evidence “anecdotal.” An example of anecdotal evidence is the story of Eric Small’s personal results with yoga and MS that I wrote about in my post Friday Q&A: Multiple Sclerosis. The fact that so far there has only been anecdotal evidence does not mean that students with MS have not noted improvements in different aspects of their illness when regularly practicing yoga, but until now no one had done a focused study on MS. Now I’m happy to let you know that a study sponsored by Rutgers University has just recently been completed that demonstrated improved symptoms for MS patients who participated in a yoga program for eight weeks. And although the published version of this study is not presently available, an early press release shares some of the findings (see Yoga Relieves Multiple Sclerosis Symptoms).

Interestingly, the study will be formally presented at the upcoming Conference on Yoga Research in Boston in two weeks! The authors note that MS “can cause poor coordination, loss of balance, slurred speech, tremors, numbness, extreme fatigue and problems with memory and concentration.” The exciting findings of the study are that after eight weeks of participating in the study, “those who participated were better able to walk for short distances [for] longer periods of time, had better balance while reaching backwards, fine motor coordination, and were better able to go from sitting to standing. Their quality of life also improved in perceived mental health, concentration, bladder control, walking, and vision, with a decrease in pain and fatigue.”And what exactly did the study participants—all women—do? 

“For 90 minutes, twice a week for two months, they practiced techniques and exercises that would improve their posture, help to increase stamina, and teach them how to relax and focus.”

And because the women had different symptoms and severity of challenges, the practices were modified to address these differences. 

“The yoga practices were done by the women in the study sitting, standing, or lying on yoga mats, and using metal folding chairs situated close to the wall to provide them with more support.” 

I am so pleased to know that the researchers addressed that yoga is not a one-size-fits-all approach to addressing balance or any of the other issues that MS patients deal with. And one of the study participants interviewed felt that the group dynamics and camaraderie also seemed to be a positive factor for her. This is a sentiment I hear from my regular students as being a powerful motivator for sticking with their yoga practice.

The downside to the new study is that it only enrolled 15 students (bigger numbers allows for stronger and more confident conclusions), they were all women (although MS affects women three to four times more often than men, it would be helpful to have had a few men included), there was not control group (MS patients who were given standard mainstream treatments but no yoga) to compare with, and there was no long-term follow-up. 

However, like most yoga studies that are done these days, this one was called a “pilot study,” so the findings are encouraging. But this pilot study really needs to be followed up with study of a much larger group of MS patients to give us those more meaningful conclusions. The authors hope that such a large future study would allow them to be able to prescribe yoga for MS patients with moderate disability. In any case, this study is step in the right direction! 

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Working with Carrying Angles in the Elbows

by Baxter

Woman Carrying a Child Downstairs by Rembrandt

In addition to the tendonitis I wrote about last week Elbow Pain and Yoga, another fairly common situation that I have observed in my students over the years are elbows that appear to look like knock knees do at the knee joint. What I mean by that is that the elbow joint seems to bow inward instead of making a straight line from the upper arm bone to the forearm bones. In anatomical terms this is referred to as a “carrying angle,” and sometimes as hyperextension. This could be considered just a variation on normal anatomy of the arms at the elbow joint, but ever since I started studying yoga in the mid-90s, it has been implied by many of my teachers that a carrying angle in weight bearing yoga poses could present some problems for those practitioners. I’ll get to that in a few moments. 

Interestingly, if you or I stretch our arm out in front of us, fully extending or straightening at the elbow, with our palm turned up toward the ceiling (known as supination of the forearms), and we look at the angle between the humerus and the forearm bones, it is usually not a straight line. The forearm bones angle slightly out to the side, away from the midline. But, wait! If you turn your hand down toward the floor (known as pronation of the forearms bones), you will likely notice that the upper and lower bones of the arm now appear more aligned! This is true for many yoga practitioners, but not all. And when the arms are not bearing weight, such is in many of the standing yoga poses (Warrior 2, as an example), it is really a non-issue for someone with a carrying angle. However, when we look at the elbows in one of the most common modern yoga poses, Downward-Facing Dog pose (Adho Mukha Svanasana), practitioners with a carrying angle will demonstrate this bowed-inward appearance while doing the pose. It will also show up in other straight arm yoga poses where you are bearing weight on your hands, such as Upward-Facing Dog pose (Urdhva Mukha Svanasana, Side Plank pose (Vasithasana), Plank pose, and Handstand to name some of the more obvious poses. 

I should mention that hyperextension of the elbow joint, where, instead of 180 angle between upper and lower arms in full extension of elbow, the angle is greater than that, is often present in those with a carrying angle. In hyperextension, it is often loose or lax ligaments around the joint that allow for the greater angle, but it is also influenced by the joint capsule and the shape of the bones. In both the situation of the carrying angle and hyperextension of the elbow joints, there is potentially less stability and even contact between the ends of the bones at the joint. This could increase the chances for wear and tear between the bone surfaces, as well as strain on the ligaments and tendons, and the development of pain around the elbow joint. 

A HUGE however: Because there is great variety in our skeletal structure, influenced by muscles and connective tissue, allowing the elbow joint to “lock out” into full extension where the carrying angle or the hyperextension become evident may not mean that the yoga practitioner is destined to develop arthritis or tendonitis of the elbow joint. So, it may be that only yogis who have elbow pain in the setting of a pronounced carrying angle should modify their poses to try to eliminate pain around the elbow. 

If you are interested in reading a great discussion on this topic (and to avoid re-inventing the wheel), I’d recommend you check out this post from YinYoga.com’s Bernie Clark: 

Now let’s assume that you or your yoga student is experiencing elbow pain in the weight-bearing poses mentioned above. What modifications can you try to attempt to eliminate the pain and quiet down the underlying problem that might be behind it? Here are a few ideas: 

1. Take a break from those poses for a few weeks and notice if the pain subsides or goes away completely. 
2. Do modified versions of the weight-bearing poses, like Half Downward-Facing Dog pose at the Wall, or Side Plank pose (Vashithasana) at the Wall and notice if less pressure through the elbow joint results in a decrease or absence of pain. Stick with those variations for a while before re-introducing the full arm balances. 
3. In Downward-Facing Dog pose, try to slightly bend your elbows until your arm bones will line up evenly. You might need someone to tell you where that alignment is if you can’t see it yourself. Keep in mind that you will now be relying more on your muscles, so it is going to feel like a lot more work and you may not be able to maintain the pose for as long as you did when the elbow was fully extended. Build strength gradually! 
4. For poses where the arms are parallel, like Downward- and Upward-Facing Dog pose and Handstand, try placing a looped strap just below your elbow joint towards your wrists, on the thick parts of your forearms. Make the loop just big enough that when you press your forearms outward against the loop your arm bones line up at that 180 degree angle. The strap will take on some of the muscular work you had to do in #3, and you will probably be able to stay longer in the poses. This could allow you to better sense the even alignment of the bones and find it on your own without the strap over time. Notice if the pain is gone when using the strap.
5. Also in poses where the arms are parallel, try turning your elbow creases to face each other (they are probably turning away from each other). Once your elbow creases are facing each other, try rolling your upper arm bones slightly out (external rotation) at the same time you roll your lower arm bones slightly in (internal rotation). See if these actions bring your arms into a straighter alignment.
6. Working with your shoulder joints and hand placement can also re-align your elbow joints, so it would be worth exploring what more external rotation or internal rotation of the humerus bones does to your elbow joints. Turning your hands slightly in or out (abduction or adduction at the wrist joint) could also bring the bones at the elbow into a more even alignment. But you have to make sure you don’t trade pain in one joint for that in another! 

There may be other suggestions that some of our readers have tried for elbow pain attributed to carrying angles or hyperextension of the elbow. What have you found beneficial? And have any of you lived with this variation of anatomy without developing any problems? Let us know you experiences and thoughts on angles at the elbow!