Longevity vs. Morbidity (Ill Health)

by Nina 

Ice by Philip Amdal

“Stated succinctly, lower mortality is being replaced by higher morbidity (ill health).” —Daniel Lieberman, from The Story of the Human Body

For some time now I’ve been meaning to write about the difference between longevity (the number of years you live) and morbidity (the number of years you spend in ill health). I think it’s an important topic because morbidity, not longevity, is the issue we’re trying to address here on this blog. I’ve definitely had people challenge me about the longevity issue, saying for example, that if overweight people live just as long as thinner people, what’s the problem? Well, the answer is that the number of years you live is not the whole story. It’s also important to consider what your quality of life might be during your lifetime, especially your later years.

“As more people are living longer and fewer are dying young from diseases caused by infections or insufficient food, exponentially more middle-aged and elderly people are suffering from chronic noninfectious diseases that used to be rare or unknown.” —Daniel Lieberman

As I’m currently reading a book by Daniel Lieberman called The Story of the Human Body: Evolution, Health, and Disease that considers this very issue from the point of view of human evolution, I decided that now would be a good time to take on the topic of longevity vs. morbidity. (Hey, it’s always easier to write about something when I’ve got lots of handy quotes from an expert, in this case a professor of human evolutionary biology and the Edwin M. Lerner II Professor of Biological Sciences at Harvard.)

Here is how the book describes the current epidemic of ill health (morbidity) in the developed world:

“Cosseted by an embarrassment of riches, a majority of adults in developed countries, such as the United States and the United Kingdom are unfit and overweight, and the prevalence of childhood obesity is skyrocketing globally, presaging billions more unfit and obese people in the decades to come. Poor fitness and excess weight, in turn, are accompanied by heart disease, strokes, and various cancers, as well as a multitude of costly, chronic illness, such as type 2 diabetes and osteoporosis.” —Daniel Lieberman

Throughout the book, Lieberman talks about how human beings evolved to live a hunter-gatherer lifestyle, one that includes being very physically active (we evolved for endurance walking and running), eating lots of fruits and vegetables and other unprocessed foods (rather than quickly metabolized high-processed foods), and experiencing stress as an acute, episodic reaction rather than a chronic state. Our bodies are simply not built to handle being sedentary for years on end, a regular surfeit of calories, and/or a chronically stressful lifestyle.

And for the last couple of years, we’ve been on a mission to let you know the various ways that regular yoga practice can help with the morbidity that is becoming associated with aging in the developing world. Although they won’t turn you back into a hunter-gatherer, the yoga solutions we’ve been offering on this blog for the last couple of years will help you move back in the right direction. A regular asana practice is a great way to return to being physical active, one that helps you with strength, flexibility, balance and agility. Yoga’s stress management tools, including meditation, breath practices, and stress-reducing poses help reduce chronic stress associated with many serious illnesses, such as heart disease and high blood pressure. And for those with weight problems, yoga can be of some help in reducing the stress that can cause overeating and the especially dangerous abdominal fat, allowing you increase your will power, and teaching you to be more mindful in your eating habits.

“Just as this is not the best of all possible worlds, your body is not the best of all possible bodies. But it’s the only one you’ll ever have, and it’s worth enjoying, nurturing, and protecting. “ —Daniel Lieberman

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Friday QA: Is Women's Flexibility a Liability in Yoga? Baxter's Response to William Broad

The Flexible Melina Meza!

Q: So, Baxter, what do you think of William Broad’s latest claim that women’s flexibility is a liability in yoga?

A: Firstly, I want to thank Shari for her level-headed look at New York Times science writer and author of The Science of Yoga William Broad’s most recent assertion that women who do yoga are at great risk of injury due to their flexibility (see Women's Flexibility is a Liability in Yoga).  Thanks, as always, Shari, for your practical experience as a physical therapist and a long-time yoga practitioner and yoga teacher. I think your insights will go a long way in helping clarify articles like these that may have an unstated agenda that colors and lessens their credibility. I’d also direct some of you to this balanced response by yoga teacher Paul Grilley to the article as well. As always, William Broad’s articles do get us thinking and talking about yoga. 

But if I read Broad’s most recent article and his latest assault on yoga accurately, am I to understand correctly that both men’s tightness and women’s flexibility are liabilities in yoga? So is yoga now safe only for animals and children? I have always encouraged men to try yoga because they seem to hold so much tightness in their bodies. And women often master the more challenging poses in yoga from a seemingly more inherent flexibility. But I also have plenty of incredibly flexible male students and an equally large number of stiff and inflexible women in my classes. 

As a yoga teacher and also a student of yoga for several decades, I find most teachers today are cautionary to their students to be mindful of the feedback their bodies give them as they approach more physically challenging yoga poses. And yet, as if to throw one more barb of accusation at yoga and its teachers, the author offers this final warning: Unfortunately, yoga teachers too often encourage students to “push through the pain.” 

With all the supposed statistics the writer offers in the article, none are offered with this statement, and I am not certain where this impression comes from. I know that this can happen in some classes and styles of yoga, but this generalization, I believe, does not represent the overall state of yoga teaching in the US today.

And the tone used by the author implies that he has uncovered some hidden or unknown risk to yoga practitioners, and, more pointedly, women, that some of them could be at risk of hip injuries or impingements. As far back as 2009, the International Journal of Yoga Therapy published an article by Elaine Goodall "Preventing and Healing Injuries in Yoga: Acetabular Labral Tears.” In her detailed article, Ms. Goodall notes that gymnasts and dancers may have a predisposition for these kinds of injuries as well as some in yoga. So much for breaking news! 

One of my difficulties with the statistics—if they can be called statistics—that are offered in the New York Times article to back up the assertion that women are at a significant risk of hip injuries of a very specific kind is statements like this:

“Each year, he (Dr. Kelly) said, roughly 50 to 75 of his patients who danced or did yoga underwent operations. Most, he noted, were women.” 

The author goes to the effort of interviewing a surgeon, getting a guesstimate from said doctor, and never follows up with: how many were yoga related and how many dance related, and how many were a combination (as many yoga students, men and women, danced when younger)? And how many were men? What meaningful conclusions can a yoga teacher make from such superficial exploration?

In addition, the author points to a 2008 study done in Switzerland that looks at the kind of unique arthritis/traumatic changes to the hip called Femoral Acetabular Impingement, or FAI. However, he fails to mention that the women in that study had unusual hip anatomy, considered abnormal, though subtly so. The authors of the study go on to say, “The focus of the new concept (the theory on what underlies FAI) addressed those remaining cases of hip OA (osteoarthritis) in which the deformity (FAI) was considered mild, slight or even, in the eyes of casual observers, nonexistent.” 

So women and men who develop this impingement injury to the hip (prior to starting yoga) already had an anatomical reason that movements in the hip joint could lead to injury. Interesting. Developmental abnormalities that usually arose prior to adulthood were present in most cases. And this kind of FAI occurs in men and women, not women alone. Only once does this study mention that the pincer-type of injury is to women with underlying anatomically abnormal hips. And that these women often participate in “yoga and aerobics.” The authors don’t say the yoga caused the problem. As Paul Grilley so astutely points out, correlation does not mean causation! In fact, yoga is never mentioned again in the fairly lengthy article, and not at all in the final wrap up discussion that usually highlights the facts they find most compelling. They also don’t give statistics that clearly outline what percentage of women, with hip pain that requires surgery, have this kind of injury (FAI). So, again, the practical applicability for us in-the-trenches teachers is very unclear.

And statements like this are just mystifying: “I found that hundreds of orthopedic surgeons in the Mediterranean region heard a conference presentation in 2010 that linked F.A.I. to middle-aged women who do yoga.” If this was true, why does he not cite the study or the “presentation”? What was the presentation based on? Who made the presentation? Was there any study to back up these assertions?

And quotes like this: “Michael J. Taunton, an orthopedic surgeon at the Mayo Clinic, told me that he first learned of the danger a half decade ago and now annually performs 10 to 15 hip replacements on people who do yoga. About 90 percent, he added, are women.” This again does not help me much, as I don’t know how many hip surgeries this doctor does each year (about 20-30 a month, I would guess), so this may represent a small percentage of his annual surgeries, but the way it is presented seems really worrisome, if not epidemic, if you don’t have all the facts.

I have been teaching about the risks and benefits of yoga to future yoga teachers now for over 10 years. Some sort of classroom instruction on the topic is included in many 200-hour beginning level teacher trainings. So, from my personal experience and perspective, the yoga community is aware of potential dangers of certain aspects of the physical practices of asana and is better defining and sharing that information with each passing day.

Despite the author’s initial statements on the wonderful potentials of yoga in the first paragraph, little that follows in his article supports this assertion. I reminded myself that the final chapter of The Science of Yoga does give some insight into the author’s feelings and motivations regarding yoga:

“Yoga can grow up or remain an infant—a dangerous infant with a thing for handguns.” 

And a bit later in the epilogue, when discussing his concerns for the commercialization of yoga, he seems to pushing for huge government oversight of yoga with the following:

“Imagine if Big Pharma had no Food and Drug Administration and other regulatory agencies looking over its shoulder. The marketing of fake diseases and bogus cures…would be much worse.” 

And in the time since the release of his book, the three articles Mr. Broad has published have only dealt with potential negative aspects of yoga: the two on the dangers of yoga to men and women and one on the sexual scandals of yoga teachers.

How about a story from this self described yoga practitioner on the benefits of yoga next next time instead of sensationalist fearmongering?

—Baxter

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Is Women's Flexibility a Liability in Yoga? Shari's Response to William Broad

by Shari

The latest New York Times article from William Broad Women’s Flexibility is a Liability (in Yoga) sparked a conversation between Nina and me, both whom are long-term yoga practitioners who have grappled with orthopedic injuries. Broad states that he has recently learned that women are at higher risk of hip injuries in a yoga class because of their inherent flexibility compared to men. He quotes a single yoga teacher, Michaelle Edwards, saying that “women’s elasticity became a liability when extreme bends resulted in serious wear and tear on their hips. Over time the chronic stress could develop into agonizing pain and, in some cases, the need for urgent hip repairs.” He also says of arthritis researchers:

The investigators found that extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis. They called it Femoroacetabular Impingement — or F.A.I., in medical shorthand. The name spoke to a recurrence in which the neck of the thigh bone (the femur) swung so close to the hip socket (the acetabulum) that it repeatedly struck the socket’s protruding rim.

I personally can’t stand sensationalism of any type and particularly sensationalism of the fear and scare tactics kind. When I first saw this article, I groaned inwardly. But I then proceeded to read it carefully, including the related links, and then went on to do some additional research of my own. After all that, my response is: maybe.

First of all, I, as a long-term yoga practitioner, am not sure what exactly he means. We all can be overly flexible in some areas of our bodies and conversely overly tight in other areas of our bodies. The biomechanical model of structure and function is a beautiful yin and yang interplay between forces that influence our bodies, and yes, can ultimately change our structure and function. Some changes may not be as beneficial as others so we need to be consciously selective and astute to observe what changes occur with function.

I also think, as in the past, Broad is careless in his citations of his evidence and is vague about these ER records of hip injuries. However, he does cite some orthopedists and one international study that do substantiate his observation that women who put their hips into extreme ranges of motion can injure their hips. Well, this is blatantly obvious to anyone who may be neurologically intact. When a joint is taken into an extreme position there is a pain response recognized by the central nervous system that warns the person to back off. Of course, if we choose to ignore the pain response, then is it the yoga that is causing the injury or is it the person who is foolishly not listening to the feedback their body is providing?

I also think that to address William Broad’s assertion that women are more flexible than men, we need a better working definition of (biomechanical) flexibility:

Flexibility is the range of motion in a joint or group of joints, or, the ability to move joints effectively. Flexibility is related to muscle strength. Flexibility is also the ability to move through a full range of motion.

Flexibility is a conscious movement that has an intricate feedback mechanism between the muscles and the nerves innervating the muscles and the joints and the central nervous system. There are significant protective mechanisms that prevent the individual from overstretching if they PAY ATTENTION to the sensation of pain rather than ignoring it.

So are women “inherently” more flexible than men? Well, it depends who you ask. But all sports attract a body type, and if yoga is considered a “sport” then there is a body type that is drawn to yoga. We all like to do things that are “easy” and for some flexible bodies yoga is “easy.” The rub here is that this isn’t “yoga” but athleticism masquerading as yoga!

So now let us look at his assertion that yoga is the root cause of “femoracetabular impingement”. The literature that I read, including one of his references, states that the subjective symptoms are deep anterior groin pain with associated intermittent catching and locking of the hip joint. In addition, there is a significant decrease in hip internal rotation. The morphology is that there is a breakdown of the hip labrum (how the head of the femur is connected into the cup of the pelvic acetabulum) and the articular surfaces of the femur and acetabulum. There is a structural change in how the head of the femur is sitting and facing, and movement of the hip will continue to tear the tissue structures with a loosening of the integrity of the hip joint. The problem is that a lot of individuals who have this condition are pain free, asymptomatic and don’t know they have it. The concern is that this condition may be a precursor to developing hip arthritis down the road. There are four types of femoracetabular impingement and one type is more common in women and one type more common in men!

Another article that I read stated that the condition is caused by internal rotation of the hip while in 90 degrees of hip flexion. Yes, this can be Uttanasana (Standing Forward Bend)! So is the problem the combination of these two movements? I don’t know, but does that mean you need to stop doing Uttanasana? I don’t think so unless it is causing pain. And, yes, there are some pretty extreme hip positions in yoga which only some of could do when we were younger (maybe can still do them now) but the bottom line is that we need to practice with intention and attention to form, function and our own bodies' abilities and not soldier on through the pain. Yoga, as we have mentioned time and time again, can be physically and mentally challenging, but is not supposed to hurt. So don’t be scared off again by a sensational journalist who claims he is a yogi.

In a future post I would like to present some of the inherent differences between male and female pelvis and hips that might also help to put into perspective the allegation of the differences between men and women.

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Building Unity Farm - The Duck Pond

As I've written about recently, Fall has been a busy time at Unity Farm.  We completed our first harvest, pressed cider, picked mushrooms, planted winter vegetables, and cared for young animals.

Although we have a year round stream running through the farm, we do not have a pond for our ducks, deer, raccoons, opossums, and other local fauna to access standing water during the winter.

This Fall we built a small pond near the barnyard.

In New England, we have very rocky soil, so we had no shortage of boulders for pond building.   Our mushroom farming work generated many spare logs.   All the building materials for a pond were already on the Unity Farm property.

We needed two things to succeed - someone to provide pond building expertise and someone who could move/carve/assemble rocks.   Together, John Novak and Sean Cudmore created the duck pond pictured above.

The engineering includes a bog area that acts as natural filter, many plants to provide oxygenation, and a pattern of circulation that keeps the surface free of debris.

The ducks are 6 weeks old and soon will be given the run of the barnyard.   Our experience with ducks thus far is that they live for water.   Our 10 ducks drink (or groom with) about 3 gallons of water per day.  They have a talent for turning any dry soil into mud.   They're not shy about spending the day in their outdoor pen no matter what the weather.   I'm convinced the pond will be paradise for them.

Maintaining a pond in winter will be a learning experience for me.   As one of the few unfrozen water sources for nearly a square mile, the Unity Farm duck pond will be very popular.

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Yoga Props: An Introduction

by Nina

Just the other day, I got this interesting request for information on using props.

Another local yoga instructor and I live in a remote/rural area, and attending high quality trainings is difficult at best. We've been looking for a training that focuses on the use of props, but we've had no luck. We are wondering if you could address in your blog, or recommend a good book, about the use of props for seniors. We are looking to create a more supportive class for seniors without taking them straight to a chair.

Well, dear reader, you’re in luck. Because it just so happens that I was trained in the Iyengar style of yoga, and, in fact, the use of props is a modern invention generally credited to B.K.S. Iyengar himself! As the story goes, at the age of 18 (1937), Iyengar was sent by his guru, Krishnamacharya, to Pune to spread the teaching of yoga to “householders .” Observing that his new students—typically older and stiffer than the boys Iyengar had been training with at the Mysore Palace—were often  unable to find a healthy and comfortable alignment in the yoga asanas, Iyengar came up with the idea of using props, including blocks (called “bricks” in India), blankets, straps, bolsters, chairs and others, to help support the students in their poses. Ideally using a prop helps you achieve correct alignment in the pose when your body is not open enough or strong enough to do the pose without the prop. Here’s a photo of Baxter doing Triangle pose with his hand on a block instead of the floor. (To be completely honest, Baxter has tight hamstrings and these prevent him—along with a lot of other folks out there—from being able to do Triangle pose with his hand touching the floor.)

Triangle Pose with Block (on highest height)

I’m telling you all this because your best bet for learning how to use props from a teacher is to find an Iyengar yoga teacher (either official certified Iyengar or Iyengar-style), though I expect by now a lot of other types of teachers have adopted them, too. For those of you who don’t have access to a teacher who is an expert at using props, we do have some information on using props on the blog. Our restorative yoga poses, supported inverted poses, and supported forward bends all use them.

I also wrote a post Making Your Own Yoga Props that provides tips for using simple household items (such as books and sashes and bags of rice) in place of “official props.” And, inspired by this reader’s question, I’ll try to write more about props in the coming weeks.

In the meantime, you can learn from using props from yoga books. I’m going to be very bold and recommend one I co-wrote: Moving Toward Balance, the second yoga book I wrote with Rodney Yee. The reason I’m recommending this one is that we both put a lot of thought into how we presented the information on using props in this book. We included a very thorough overview of the types and purposes of props in the chapter “Preparing to Practice,” which even tells you how to fold yoga blankets! And we systematically provided an easy alternative for every single pose in the book, many of which use props. We also tried to keep the use of props very streamlined and simple because we were concerned that for people practicing at home, needing a large number of props to do a pose could be off-putting. Although these “easy” versions of the poses weren’t designed especially for seniors, I think you’ll find many of them totally appropriate versions that are in between the full version of the pose and doing yoga on a chair. And even the ones that don’t use props (such as the easy version of Warrior 2, which has hands on the hips and an only slightly bent knee) will be very suitable for older beginners.

I’ll also recommend The Woman’s Book of Yoga and Health, my most frequently used yoga book. The last section of the book, which is for older women, has some great examples of yoga poses done with props.

You can see classic Iyengar propping in Iyengar’s book Yoga, The Path to Holistic Health. Some of the propping in this book will be very useful to you, though some, well, may just be too complex and/or elaborate. The elaborate setups tend to be employed in specially equipped yoga studios by Iyengar teachers who are trained in their use.

Once you get into the swing of using props, you may find that you are coming up with your own inventions! My own teacher is constantly coming up with new ideas, which stem out of his personal practice. And I myself have come up with a few nifty ideas….

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Quality Measurement 2.0

I've written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification.   The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.

There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders - providers, government, and payers.   Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.

How do we fix CQMs?

1.  Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs.   Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations.   This is a good start.

2.  Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM.    The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.

3.   Greatly reduce the number of CQMs required by private and public entities to a consistent, manageable number.  That way we can focus on ensuring integrity of data elements used in quality measures.

This approach will create a “healthy tension.”   If HHS restricts measure developers from using an infinite number of data elements,  measure developers will express concern that available technology is limiting quality measurement.  If measure developers continue to include data that does not exist in the EHR, then developers will create burdensome add-on data entry screens to prompt providers for extra information just for the sake of CQM.

A few years ago, Jacob Reider (now the Acting National Coordinator) created these slides that illustrate how to cross the Quality Measurement chasm - modify expectations of quality measurement developers, while also enhancing EHRs with value sets from the VSAC and continuing to develop standards that support quality measurement (such as FHIR), optimizing workflow and usability.

As I've said before, I will do everything in my power to support Jacob Reider, ONC and "polishing" of Meaningful Use Stage 2.

Revising CQMs is likely to be a high priority of the HIT Standards Committee over the next year.    Watch for that discussion at the November 13 HIT Standards Committee meeting.

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Chronic Fatigue Syndrome and Yoga

by Baxter

Floating Leaves by Melina Meza

As we once again pass through the man-made time shift that is daylight savings time (ughh!), I always notice a general malaise and sluggishness in many of my students.  The frequency with which my folks report colds and flu goes way up, and the request for longer Savasana at the end of class is a regular phenomenon. But on occasion, a student will report ongoing fatigue that goes way beyond the seasonal shifts or illness exposure of the fall and winter season. Some of these students return from a visit to their doctor with a tentative diagnosis of Chronic Fatigue Syndrome (CFS). 

It is very likely you know someone with this condition. According to a 2003 study in the Annals of Internal Medicine, the prevalence—the total number of cases of a disease in a given population at a specific time—of CFS is 235 per 100,000 people, with women three times more likely to develop CFS than men.

But just being tired a lot does not get you the diagnosis of CFS. The Mayo Clinic defines chronic fatigue syndrome as:

“a complicated disorder characterized by extreme fatigue that can't be explained by any underlying medical condition. The fatigue may worsen with physical or mental activity, but doesn't improve with rest.”

In fact you have to have significant fatigue for at least 6 months, along with 4 of the following other signs or symptoms, according to the Mayo Clinic:

• loss of memory or concentration
• sore throat
• enlarged lymph nodes in your neck or armpit
• unexplained muscle pain
• pain that moves from one joint to another without swelling or redness
• headache of a new type, pattern or severity
• unrefreshing sleep
• extreme exhaustion lasting more than 24 hours after physical or mental exercise

The cause of CFS is still unknown, although there are many theories about how and why it develops, including post-viral infection complication, abnormal immune system function or endocrine system function. And there are no specific tests to “prove” you have CFS, so it is important to rule out other conditions that can be associated with fatigue, like sleep apnea, certain medical conditions (like anemia, diabetes or hypothyroidism) and mental health conditions (like depression and bipolar illness, to name a few). 

Patients with CFS can a lot of variability in their symptoms, with some days better than others, and flares of symptoms can happen with minor increases in activity. However, because the condition does not get better with rest, the recommendations for treatment by your doctor will include medications, physical therapy and lifestyle modifications. Encouragingly, the Mayo Clinic site actually recommends yoga to help manage the pain symptoms of CFS. And although the studies of the effects of yoga for CFS are yet to be done, the Centers for Disease Control does recommend yoga as a part of treatment approach for CFS.

Many of the yoga recommendations I have made for other chronic illness would apply here as well.  Start out slowly, with small, gentle yoga practices, even done in bed. Working with an experienced teacher or yoga therapist initially will give you the greatest chance of gaining benefits from adding yoga to your treatment. Since yoga has been shown in studies to have benefits for stress reduction (an aggravating factor for CFS), and improvements in both endocrine and immune function, systems that can be out of balance in CFS, yoga will likely affect more than just the pain symptoms.

And, as we always advocate here at YFHA, “yoga” implies using as many of the tools of yoga as are appropriate for each individual. If you added in an Ayurvedic perspective, attention to diet and sleep would be included in as well. And on days when a more active physical practice seems daunting or counterproductive, breath work, guided imagery and meditation, including yoga nidra, will allow you to still “practice.” Just the ability to do some sort of practice regularly can give the person with CFS a greater sense of control over their health, which can foster a greater sense of healing and improve their outlook. And as the student progresses to greater levels of ability with the physical poses, which a physical therapist would refer to as “graded exercise,” attendance in a gentle yoga class would be recommended to combat the tendency to social isolation that can often accompanies the lives of those with CFS. Due to the uncertainty of how long CFS may be around, establishing a yoga practice as an ongoing, daily part of your life will have benefits far beyond its effect on only one aspect of your health. 

If any of our readers have personal experiences with the pros and cons of yoga for CFS, please write in and share this valuable information with your fellow YFHA readers. Thanks!

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Breathing, Chronic Obstructive Pulmonary Disease, and Yoga

by Shari

In my “day job” as a home health physical therapist, I see a lot of clients who have significant breathing difficulties. One of the most common breathing ailments is Chronic Obstructive Pulmonary Disease (COPD). COPD is similar to asthma in that some of the symptoms are the same but the etiology of the disease is different. Most significant is the inability to get air out and not being able to get enough oxygen in.

Let me give you a bit of background about breathing and normal airways. Air travels into the lungs via the trachea. It goes down a series of branching airways called bronchi. These bronchi branch into smaller bronchioles and then into millions of tiny air sacs called alveoli. Oxygen in the air passes through the thin walls of the alveoli into the tiny blood vessels nearby, attaches to red blood cells and is carried into the blood vessels to the rest of the body. Carbon dioxide is passed out into the alveoli from the red blood cells and is breathed out. But breathing doesn’t always depend upon the oxygen needs of the body. Breathing can be related to emotions, body tension, sensations of pain, pleasure, and body movements.

Breathing is composed of two main parts: inhalation and exhalation. Inhalation is the process of taking air into the lungs. It can occur with different amplitudes or volume of air. It can occur at a variable rate, and it can be less active. Exhalation is the process of letting air flow from the lungs back outside the body. It can vary in amplitude, rate and effort. You can stop your breathing but, of course, not permanently.

There are two main types of breathing: costal (ribs) breathing and diaphragmatic breathing. In costal breathing the ribs open and close primarily and in diaphragmatic breathing the abdomen changes shape.

The volume of air that one breathes in inhalation is called “tidal volume” and in rest or relaxation it is at a minimum. When we do moderate activity, we increase the amount of air that is bought into the lungs but this doesn’t change the tidal volume.  When we maximally exhale the air from our lungs, there is always some air left in the lungs and this is called residual volume.

Other factors that influence the depth of our breath include rib cage flexibility, (the more flexible the rib cage, the more we can increase the amplitude of our inhalation) and muscular strength of the muscles of exhalation. The diaphragm is the primary muscle of inspiration. The secondary or accessory muscles of respiration include many muscles of the ribs, neck, chest wall, and trunk (abdominal muscles).

The Diaphragm (with ribs cut away)

When we breathe, the diaphragm contracts and moves downward if the abdomen is relaxed. The belly will then gently expand outward and the lower regions of the lungs expand downward. When we exhale, the diaphragm relaxes and moves back up, the belly moves in a bit.

An individual with COPD works very hard to breathe. Often there are postural changes that occur over time that may be structurally compromising the ability of the rib cage to expand and return to resting position. If the anterior chest wall is collapsed and tight, then we don’t have the rib or thoracic flexibility to encourage the lungs to fill to their capacity.  Breathing involves muscles, skeletal and joint articulations and is an interface of organs and movement.  But breathing is also an emotional activity.

Because an individual with COPD is chronically short of breath, they fear movement because it makes them short of breath, so in turn they become chronically deconditioned, and weak due to immobility. The fear of not being able to breathe leads to increased anxiety, depression and more fatigue and stress. Here is where the practice of therapeutic yoga can be so beneficial for an individual with COPD.

If we consider the individual fully and address their physical, emotional, neurological and spiritual nature, we can assist them in learning to move again within the confines of managing their respiratory issues. Learning to observe one’s breathing pattern and to gently try to increase the exhalation compared to the inhalation is quite beneficial for someone with COPD. Gentle asana practice that addresses areas of chronic tightness and postural awareness with improved skeletal flexibility allows more freedom of respiratory movement. Please see all our wonderful prior posts for gentle seated practices and safe gentle yoga poses. Also please reread the pranayama posts because these can be adapted to a COPD breathing pattern if the emphasis is on the exhalation with no retention holds at either the end of inhalation or exhalation. Lastly, trying to walk with good self pacing and breathing awareness (sort of like a meditation practice) is a wonderful way to begin to address the poor endurance that plagues someone with COPD. If you yourself have COPD or know someone with COPD who wants to study yoga, I would recommend individual private one-on-one yoga sessions to start, and then, if and when possible, moving on to a gentle yoga class that is slow paced.

Note: November 16, 2013, Shari and her colleague, Bonnie Maeda, will be teaching a workshop in Brentwood, California on Yoga for Breathing and Sleep Apnea, which covers COPD and other topics. For further information or to register for the workshop, see brentwoodyogacenter.com.

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Friday Q&A: Costochondritis

 Q: How can yoga help people that have costochondritis? I have it now and then and I can't do some yoga poses that open the chest as they trigger the pain. I had it for the first time 3 years ago and it never really went away, keeps coming back.

A: Costochondritis (CC) is a fairly common cause of chest wall pain in adults in the US and around the world. According to the Mayo Clinic website: 

“Costochondritis (kos-toe-KHON-dri-tis) is an inflammation of the cartilage that connects a rib to the breastbone (sternum) — a junction known as the costosternal joint. Pain caused by costochondritis may mimic that of a heart attack or other heart conditions.”

This last statement about this kind of pain mimicking heart attack has led many a student of mine with sudden onset of chest pain to the hospital, fearful they were having one! In the case of costochondritis, all the tests come up normal, which is obviously a huge relief, but the pain can persist, as it has for our reader.

Let’s look at some other facets of costochondritis before we specifically look at what yoga’s role is in helping or hurting it. Modern medicine’s view on CC is that most of the time there is no apparent cause for the inflammation between the rib and cartilage, which can be frustrating if you have it because if you knew what caused it, you could change what you are doing to possibly avoid it happening again! So the focus shifts to treating the pain, usually with anti-inflammatory medications like ibuprofen, as well as modifying your activities to avoid movements that aggravate your pain. Since most of the connections between the ribs and breastbone involved are located to the right and left side your breast bone, this is usually where the pain shows up. Apparently, it shows up more often on the left side of the breastbone (same area some heart attack pain can be) and often involves more than one rib.  One distinguishing feature that sets it apart from heart pain or angina, is that the pain from CC often happens with a deeper breath or when coughing. 

And although I mentioned above that most cases of CC have no known cause, some cases are associated with a blow to the chest, heavy lifting or strenuous exercise, severe bouts of coughing, certain types of arthritis, or the spread of tumors to this area. In addition, you are at greater risk of developing a bout of CC if you are woman or if you are over 40 years of age. The diagnosis of CC is usually made when your history is consistent with the kind of pain I described above, if you are tender-to-touch over the side of your breast bone or when you move your chest and arms in certain ways, and if you have ruled out more serious problems, like heart pain, GI reflux or lung related illnesses, like pneumonia. Hopefully, you won’t have to do the ER full heart work up like one of my students had to undergo this past week!

In addition to NSAIDS like ibuprofen, your doc might add other medications to your treatment regimen. If the pain is severe, a narcotic medication might be suggested. If the condition lingers and becomes more chronic (which does not happen often but does happen), certain anti-depressants and anti-seizure medications can be added, not for depression or seizures, but because they have been found useful for chronic pain management. The downside to all these meds is that they often have unwanted and occasionally serious side effects.

On the non-medication side of things your doctor may recommend, you might be referred to a physical therapist, who could teach you gentle stretching exercises (ding, ding, ding!) or the use of an electrical stimulation unit called a TENS unit. On your own, you can experiment with the effect of ice or heat on your symptoms to see if they provide any relief from the pain, as well as good amounts of rest to avoid aggravating activities.

Our reader is interested in how yoga might be used to help costochondritis, but also, I suspect, how to do so cautiously, as she has noticed that the yoga asana can also aggravate or trigger her CC pain. And therein lies the rub. If you are pain free, a regular yoga practice can keep the rib cage and the joints that CC affects mobile and the muscles in the region strong and open. A regular yoga practice has been found to improve conditions that could lead to costochondritis, such as arthritic conditions. And yoga has been found to decease inflammation in those who practice it regularly, so it might help reduce the chances of developing CC in the future.

On the other side of the fence, some forms of yoga and certain yoga poses fall into the category of strenuous exercise or stressful activities for the sternal joints. Dhanurasana (Bow pose) comes to mind as a pose that stresses the joints along the sides of sternum as it stretches the front chest, and a 90-minute power yoga flow with lots of Chatarunga Dandasana could also overtax the front chest joints as well.  So you would want to assess if you developed CC within a short time of doing such poses, and give ‘em a rest if you make the connection.

Hopefully, your yoga practice is not the source of this kind of pain. But once costochondritis shows up, you will likely need to assess, monitor and modify your poses and practices if they seem to trigger or aggravate your symptoms. It is almost always a safe bet you can do supported restorative style poses, as they are less likely to negatively affect the front chest if done with the goal of keeping that area quiet.  And supported, gentle practices are likely to lower your stress response, which should have a positive impact on healing.  They should also allow your immune system to function optimally, thereby reducing the chances of developing new respiratory illness like the common cold, thus avoiding illness associated with coughing. In addition, always think outside the yoga asana box, and add in gentle pranayama (probably not long, deep inhales and exhales for a while), visualizations and meditations in supported positions while the inflammation around the breastbone joints diminishes. 

And as the pain symptoms of costochondritis diminish, gradually re-introduce more active poses and practices to get your body back to its previous healthy balance, hopefully leaving the memory and risk of recurrence of costochondritis in your rear-view mirror. 

—Baxter

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