Fine Tuning the National Healthcare IT Timeline

I've recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I'm seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard.   Priority setting is appropriate.   Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks?

Because of the complexity of the Meaningful Use stage 2 certification process, many stage 1 certified products have not yet been certified for stage 2.   Those that are stage 2 certified have only been recently introduced into the marketplace, making upgrades, training, testing, and full implementation before July 1, 2014 (the beginning of the last reporting period for hospitals which attested to stage 1 in 2011 and 2012) very challenging.   I believe that we could see hundreds of hospitals fail to attest to Meaningful Use stage 2 by the current deadline, despite their best efforts.

We learned from healthcare.gov that end to end testing with a full user load and complete data set is important to validate the robustness of an application.   ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away.    Does CMS have time for a full end to end test of all functionality with its trading partners?   I am concerned that not enough time is available.    Will most payers and providers be ready to process transactions on October 1, 2014?  Maybe.   Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place?  Doubtful.    Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign?  Certainly.    The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US.   The consequences of a delay in enforcing ICD-10 use are minimal.

ONC federal advisory committees are taking testimony from multiple stakeholders regarding the technology and policy readiness of provisions in the HIPAA Omnibus rule such as the Accounting of Disclosures and private pay redaction requirements.    It's very clear that more time and more research is needed before these elements of the law can be enforced.

The Affordable Care Act has many provisions including a move from fee for service to reimbursement based on quality. Quality measures were to be automatically submitted using the QRDA standard.  On November 5, CMS backtracked and announced that they would not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process called GPRO.   It is clear that CMS is not ready to move forward with ACA implementation on the original planned timelines.

So what should we do to fine tune the national healthcare IT timeline?

Meaningful Use Stage 2 attestation timelines should be extended by 6 months to enable recently certified products to be fully implemented in a safe and thoughtful way.    90 day reporting periods for hospitals begin October 1, 2013 and for eligible professionals begin on January 1, 2014.  Attestation must be completed within one year.  Extending attestation to 18 months will give us time to implement new software upgrades properly.

ICD-10 enforcement deadlines should be extended by 6 months to enable additional testing and workflow redesign.  The October 1, 2014 deadline may work for some providers and payers. Transaction flow can begin if systems are functional.   However, a 6 month extension will enable providers and payers to revise and improve systems before a mandatory full cutover.   We need to do this to avoid another healthcare.gov situation.

The Accounting of Disclosures and private pay redaction aspects of the HIPAA Omnibus rule should be delayed until pilot implementations can be studied and lessons learned broadly shared, likely a year.

Affordable Care Act implementation should await for maturity in the tools needed to support care management and quality reporting, likely another year.

All of these projects can be done and are reasonable components of national efforts to improve quality, safety, and efficiency.

However, the well meaning people who devised the policy principles did not take into account the operational requirements to do all this work simultaneously.   We should keep moving forward on these goals, but need to adjust the pace.    We all want to finish the race and not collapse before the finish line.

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The Importance of Independence (and Interdependence)

by Baxter

Bee & Flower by Melina Meza

Yesterday Nina dove into three key aspects of Healthy Aging, and I wanted to pick up the ball on the middle concept, that of maintaining “independence.” As Nina mentioned in her post What is Healthy Aging, Anyway?, one goal of aging well is to “continue to live independently and care for ourselves as long as possible. And Nina outlined many of the independent skills we would ideally love to preserve as time goes on: “the basic daily self care activities, such as dressing, going to the toilet, getting up and down from a chair, doing light housework, and so on as well as the ability to continue to do the activities we love.” And indeed, a regular asana practice that is appropriate for our stage of life, as well as our unique health and physical challenges, will likely keep us on track in maintaining our independence. 

As I have mentioned in previous posts, loss of independence in my patients can be one of the most dramatic and potentially devastating changes that they will face in their lifetime. The more significant the loss of function, whether physical, mental or emotional, the more likely the individual will require intensive help from others to deal with the daily issues of life, possibly requiring in-home or nursing home care to stay safe and alive while recovering or adjusting to their new reality. Anything we can do to preserve independence is really crucial the older we get.  As we discussed a few months back (see From Independence to True Longevity), the simple ability to go from standing to sitting on the floor and back to standing is also a predictor of mortality, or the likelihood of death. The study done in Brazil noted that the worse you scored on the rating scale of what we call “transfer ability,” the more likely you were to die in the six years the study lasted.

So lately in my teaching, I have been emphasizing yoga postures that contribute to the ability to get up and down from the floor with greater strength, balance and ease. Variations of Powerful Pose (Utkatasana) seem to be popping up in just about every class I teach. In my Back Care class, we even practice transferring from standing to sitting in a chair and back to standing, keeping the feet symmetric, finding the safest alignment of the spine and pelvis, and maintaining as much control of the speed of descent and ascent when sitting and standing. And because of the high rates of osteoporosis in both women and men (50% of women over 65 and 25% of men over 65), that kind of control may translate into fewer falls for those with or without OP, and fewer fractures. If you don’t fracture your hip, you are much more likely to be around in two years than if you do! 

The other place were we want to be independent is on the mental level. Maintaining mental agility and learning new tasks as we age is going to also contribute to our independence. As an online educational text from the Cleveland Clinic noted:

“Decline in cognitive abilities contributes to decline in functional independence. With normal aging, processing speed of the brain declines and recall time increases.”

The researcher pointed out that western medicine deals with this not in preventative way, but by treating conditions like dementia after they arise in a patient. As they clearly note : “Current research has been focused on treating the consequences of dementia, but no treatment modality is currently available to reverse the process or halt its progression.”

Could yoga be that modality? Something as accepted and commonplace in our culture as using a computer or smart phone can be daunting to use or learn for some as they age, but utilizing the practices of yoga that cultivate mental and emotional calmness and lower our perceived stress levels can contribute to better and faster learning skills. And a recent study has showed that meditation practice may actually strengthen the brain (see Meditation and Brain Strength). Researchers found that long-term meditators have larger amounts of gyrification (“folding” of the cortex, which may allow the brain to process information faster) than people who do not meditate.

And the ability to maintain emotional equilibrium that Nina mentioned in relation to “Equanimity” yesterday, I believe, will also contribute to overall independence. It is also important to stress that when I talk about independence, I don’t necessarily mean living alone as we age.  Studies show that men live longer when married versus single, and women tend to live longer if they have a strong support community versus being in or feeling like they are in isolation. So we are talking about having a good degree of personal independence while acknowledging the importance of interdependence and community. In fact, a 2005 study done in Israel, looked at the factors that influenced genetics in contributing to longevity in adults from 70-82 years of age.  They found that “Increased physical and social activity is an important tool to lengthen the span of robust function.” So the group dynamics and sense of community of our modern yoga classes could actually be another way to feed that social factor that can also contribute to maintaining independence as we age.

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Social Networking for Good

I've written about many aspects of social networking in the past such as

*Security risks and policy implications

*Support for research collaboration

*Applications in performance improvement

*Opportunities to reduce the provider documentation burden

One aspect I have not written about previously is the use of social networking for good such as fund raising for noble causes.

Just as I mentor 2-3 graduate students at a time, my wife has mentored fellow artists and supported them via Hatchfund

Although I've donated my time to various technology accelerators such as Rock Health, Tech Stars and Healthbox, I've not spent time on Kickstarter  or other crowd funding websites.

My wife told me tonight that she has made small contributions to worthwhile causes in the art, farming advocacy, and social cause areas.

Whether it's philanthropy, angel investing, or creating good karma, I find donation decisions to be very personal.    I've written many times that I want to make a difference and seeing tangible results on a small scale by using a social networking fundraising site seems more tangible than a donation to a large and anonymous organization.

Over the next year, I'll be working on creating my own social networking for good to fund innovation in healthcare IT.

In the meantime  I'll be paying more attention to crowd funding sites as I allocate my own contributions.

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What is Healthy Aging, Anyway?

by Nina

Dahlia by Melina Meza

It has only struck me recently that while we’ve written about what aging is and the many ways yoga can help foster healthy aging, we’ve never really addressed what “healthy aging” is. So I thought I’d take a moment to give an overview of the thoughts that Baxter and I currently have on this topic. At this point—we’re still just discussing these ideas—we consider healthy aging to have three important aspects:

• Compressed Morbidity
• Independence
• Equanimity

And the reason why we’re such proponents of yoga for healthy aging is that we believe yoga can help with all three of these aspects of healthy aging. For now, I’ll just give you a brief overview of how.

Compressed Morbidity. Last week I wrote a post Longevity vs. Morbidity comparing the difference between longevity and morbidity. The medical term “morbidity” refers to the period of time you spend in ill health before you die. Obviously we all would like—both for ourselves and for our loved ones—to keep this period of ill health as short (that is, compressed) as possible. A well-rounded yoga practice, especially one that includes stress management, can help by preventing some of the diseases, such as heart disease, high blood pressure, and diabetes that plague people during their older years.

Independence. Another goal I think we all share for ourselves and our loved ones is that we can continue to live independently and care for ourselves as long as possible. From our point of view living independently includes both the basic daily self care activities, such as dressing, going to the toilet, getting up and down from a chair, doing light housework, and so on as well as the ability to continue to do the activities we love (which I wrote about in my post Being Able to Do What You Love) for as long as possible. A regular asana practice—even one that is modified over time—will help keep us able bodied, rather than sliding into the stiffness and weakness that results from a sedentary lifestyle.

Equanimity. For me, maintaining emotional stability as we age is the most important aspect of healthy aging. For even if we can “compress” morbidity, we will certainly have to go through poor health at some point. And even if we can prolong our independence into old age, we may eventually have to face the loss of that, however briefly. In addition, even if we are ourselves blessed with long and healthy lives, we’ll all have to deal with losing people we love. So being able to handle the challenges ahead with balance and grace is crucial. But I also believe that this is where yoga has its greatest strength. Stress management practices help reduce stress, anxiety and depression. And meditation and yoga philosophy can help us keep grounded and strong. At least that is my fervent hope.

Baxter and I will be writing more on these topics in the weeks to come, but we’d also love to hear your thoughts, ideas and personal stories.

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Friday Q&A: Pain After a Knee Replacement, Part 2

This week’s question is a follow-up question that came in after the post we did on yoga and knee replacements (see Knee Replacements and Yoga) and Shari's answer to another reader about pain after a total knee replacement (see Friday Q&A: Pain After a Total Knee Replacement). It seems that pain isn't uncommon after a knee replacement, but in this case, the pain is coming several years after the replacement:

Q: My partial knee replacement was April 2007. I started back to Yoga this past summer-one day a week, but I found child pose with the knees wide uncomfortable, but I did do it for a few weeks this fall. I now have some pain in my knee and I'm hoping that I haven’t loosed the cement in the joint. Any help would be appreciated.

A: Thanks for writing in about this new pain in your knee. As always, I am not able to diagnose or prescribe a yoga program for you without first doing a more detailed history and physical exam in person, but I can share some thoughts that come to mind from the situation you find yourself in.

One of the challenging things to discern for new yoga students, or those returning after a long break from doing yoga is: How to gauge if “uncomfortable” is a potentially harmful warning sign from your body? This is tricky, because it may simply be that you are getting some intense sensation feedback from the body as you stretch and strengthen parts of your body that have been neglected for a long time. With the knees in particular, learning to recognize the difference between the healthy stretch sensation of the muscles and connective tissue lengthening versus the compression of the tissues and bones that often happens deep folds of the knee joints is an important skill to cultivate. The compression sensations can sometimes indicate pinching of tissues that could lead to inflammation, injury or bruising that may not resolve quickly or could lead to more chronic pain. It is sometimes hard to skip these poses—like Child’s pose—in a public class since they are so common unless you have an alternative offered by your teacher.  I often suggest that folks with knee pain flip onto their backs and draw the knees to the chest, essentially an upside down Child’s pose. Then almost all the pressure is off the knee joint and usually no pain is felt. The other thing to try is to vary the distance of the knee spread in regular Child’s pose until you find a distance that does feel uncomfortable.

It is also important to recognize that undergoing a knee replacement does not equal having the same healthy knee anatomy and movement you had before the surgery and the underlying knee problem that lead to your surgery. One of my students who had knee surgery to clean out a lot of arthritis damage to his cartilage found that his range of motion was less after the surgery than before, but he was now pain free. His challenge became how to gradually see if he could improve the range of motion without leading to recurrent pain.And another student of mine who had one knee replaced, but also had a second bad knee, found that although the new knee operated normally, the second knee become more painful secondary to the new way he was walking with essentially two very different knees. And sadly, having a successful repair does not guarantee that future dysfunction and pain will not arise.

In this case, it is also important to recognize the effect of the passage of time on both the surgerized knee and your other knee. A substantial amount of time has passed from 2007 until this summer of 2013. And with that the knees can undergo gradual changes in the architecture and function of the joint, such that the repaired knee can undergo undesirable changes, and unrelated changes could also have taken place. It could be that something has loosened in the replaced knee parts, but it could just a likely be some other structure, tendon, muscle or other structure, that could be the source of this new pain. This needs investigating! 

Until you have an exam and get a diagnosis from your orthopedic MD, avoid the positions that create immediate or delayed pain in the affected knee. Poses like Child’s pose include Hero pose, Thunderbolt pose (as well as poses that have just one leg in the deep flexion fold at the knee joint), front knee in Pigeon pose variations, the front knee in deep drop knee lunges, and any Lotus preps or full and half Lotus pose. Even some simple seated poses like Sukasana (Seated Crossed Legs) can be worth avoiding until you know what you have going on. Once you get a clear picture of what is happening, I’d suggest setting up a private session with an experienced yoga teacher or yoga therapist to design a home practice that can address your unique situation.

—Baxter

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Continuing To Do What You Love

by Nina

The other day Baxter and I were talking with an editor about a possible book on Yoga for Healthy Aging—isn’t that exciting?—when he said something about healthy aging that really struck me. We were going through the possible definitions of "healthy aging" (look for a post on that topic from me soon) when he mentioned that for a lot of his students, healthy aging meant being able to continue to do the activities they loved. Some examples he gave included a woman who wanted to be able to take her grandchildren on hiking adventures and another who wanted to be able to continue with her intensive gardening work.

What's so great about yoga is that a regular yoga asana practice can help with these goals for healthy aging. You can use your yoga practice both to fortify yourself and balance your body to keep yourself in shape to continue doing what you love.

Kale by Melina Meza

Let’s take the example of gardening because that’s something I do a lot myself. Gardening can actually be quite hard on your body. You spend a lot of time bending forward, which can be hard on your lower back. Bending forward also stretches the back side of your body (your legs, back, etc.) while creating tightness in the front body, the same way that sitting at your desk all day does. You also use your arms stretched out in front of you all day, which tightens your shoulders. And you need strength for digging holes, and the occasional lifting of bags of fertilizer, large plants, etc.

But you could easily plan a “gardeners” yoga practice. Backbends would strengthen your back body, stretch your front body, and restore the natural curve of your lumbar spine that gets overstretched from all the forward bending. Backbends would also help stretch the fronts of your thighs and strengthen the hamstring muscles in the backs of your thighs, balancing the strength and flexibility your legs. Twists would help release tension from your back, as well as strengthening back muscles and bones. Upper body strengthening poses (see Upper Body Strength the Easy Way and our many posts on individual upper body strengthening poses) would help you maintain your strength, and shoulder openers (see Standing Shoulder Stretches and Opening Tight Shoulders) would help you keep your shoulders flexible. Full and/or gentle inverted poses where your legs are elevated, such as Legs Up the Wall and Chair Shoulderstand (see All About Supported Inverted Poses), would foster good circulation in your legs and relieve pressure and possible swelling in your feet, ankles or legs from being on your feet all day. And if your gardening session causes mild back pain, a back care sequence, such as Low Back Care Sequence, would help relieve it.

For each activity—whether it is hiking, surfing, cycling, traveling, playing with your grandchildren, cooking for family and friends or hula hooping—you could come up with poses specifically targeted to help you maintain the physical skills you need. But because a balanced yoga practice helps you maintain strength, flexibility, balance, and agility as you age, any regular yoga practice is going to be helpful for all these activities. And fortunately for many of us, yoga is one of the activities we hope to continue doing as we age, and that’s what this blog is all about!

What are your favorite activities you’d like to keep doing as you age?

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Building Unity Farm - The Powder House Keeper

One of the great benefits of owning a colonial era property is that you never know what you're going to find.

James Bullard was born in Sherborn on August 25, 1762 and died on June 30, 1828.

He's buried in our backyard.

As I've written about previously, the town of Sherborn stored its gunpowder on the Unity Farm property in the Powder house from 1800-1857. The Powder House was accessed via Powderhouse Lane, next to the Bullard Family home at 33 Main Street.   James Bullard was assigned the role of Powder House keeper, which was especially convenient since the Powder House was about 100 feet from his back door.

The Bullard Family home is now called the Sherborn Inn and the Powder House has been dismantled, although the foundation is still visible and accessible via Unity Farm's Marsh Trail.

James was married to Mary Harding on November 9, 1786.

On the day of their 227th wedding anniversary I was cutting wood on Unity Farm's Gate Path.   The late fall sun shone through the leafless forest and reflected off a piece of bluestone in the forest.   I looked closer and found that the light was coming from James Bullard's gravestone, near one of our old pasture walls.

As I looked around the grave I noticed an old cedar with something hanging on it.  Above the grave, an old wooden snow sled, silvered and shrinking with age, hung from a branch.   There's no brand, no label, and no clear attribution on the sled.     Was this James Bullard's "rosebud"?  Was his gravesite located on his favorite sledding hill on the land behind his 1700's home?

Mary Harding,  James' wife, died in 1796 at the age of 33 and is buried in the Plain Burial Ground in Sherborn.   James is buried on our farm under a mysterious gravestone in the woods, guarded by an old cedar supporting an ancient snow sled.

I'm not sure what it all means, but of all the Revolutionary War artifacts on Unity Farm, the grave of the Powder House keeper was not something I expected to find.

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The November HIT Standards Committee

The November HIT Standards Committee focused on the current status of certification and attestation, readiness of standards for patient generated data, ONC S&I Framework progress, and the overall HITSC workplan.

Jacob Reider, Acting National Coordinator, joined us and offered his perspective on the work ahead as a physician, informatician and marathon runner.   Our goals include meaningful use, as well as many other future looking functions required by many stakeholders in industry, government, and academia.

We reviewed the themes of the meeting which importantly focused on the scope, timing, and resources we need to be successful.  Doing too much, too fast, with limited resources is not going to get us to the finish line.

We started the meeting with a Policy update from Jodi Daniel  including FDASIA, Joint Commission and safety efforts.   An important foundation to that discussion was presentation of the current state of certified technology adoption.

Next, Leslie Kelly Hall presented preliminary high level recommendations from the Consumer Technology Workgroup for the standards required to collect data from patients and devices as well as enable bidirectional care coordination and communication with providers.

Doug Fridsma presented an S&I Framework Update of projects funded by ONC and other government agencies.  I asked the Standards Committee to comment on the scope of work - should we recommend more or less S&I initiatives given available resources?   We recognized that many of these initiatives are funded outside of the Meaningful Use process, so priority setting is up to ONC and its paying customers.

Doug Fridsma also presented the Standards Committee workplan priorities as suggested  by HIT Standards Committee members.     Although we need to separate the "mediums" into those we do and those we don't, there was uniform consensus that a focus on image exchange, quality measurement, referral workflow, record locator services, and care plans makes great sense.

A very productive meeting.

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Cultivating Healthy Relationships: Yoga to the Rescue

by Ram

Jelly Fish by Melina Meza

It is difficult to live in complete isolation. We all need the support of other people around us to survive. So we develop relationships with others whether on a personal, professional, or commercial level. Thus, interpersonal relationships have a critical role to play in our lives. In order to lead a happy, smooth life, an individual must have healthy relationships with others around him. In other words, the secret to a happy life is a healthy relationship. We all have a natural drive toward establishing relationships and in these relationships we long for acceptance. A healthy relationship is one in which all the individuals feel that they matter. A healthy relationship is characterized by:

• harmony among all individuals
• a natural desire to foster additional relationships
• an effective and harmonious communication between individuals in the relationship
• a tendency to be patient with or tolerant of the opinions or practices of others
• increased sense of belonging and worth
• increased sense of enthusiasm to nurture the growth-fostering relationship

In contrast, an unhealthy relationship is damaging to one or more individuals physically, mentally or emotionally. Unhealthy relationship is generally characterized by mistrust, emotional upheaval, arguments, jealousy and possibly cheating, among others. When these issues begin to dominate the majority of the time spent together, the relationship turns unhealthy. All the above-mentioned issues invoke a common underlying theme “himsa” or violence. Unhealthy relationship can trigger violence that appears in so many forms leading to physical and mental stress. The stress of being in an unhealthy relationship has the obvious physical and psychological impact: it often increases one’s vulnerability to illness and may cause the victim to be more susceptible to disease. Battered victims experience depression, feelings of low self-esteem and helplessness coupled with somatic complaints. Their ability to trust and form emotional attachments is severely impacted.

Empathy, trust, patience, faith and compassion are some excellent tools to help cultivate healthy relationships, as these tools allow us to accept events as they are and act with an open and loving heart. The tools also replace violent tendencies with kindness, acceptance and love. Practicing them on oneself helps to cultivate the same feelings towards others. Furthermore, establishing relationships with individuals who have access to natural inner peace and a non-harming attitude can lead to a stronger ability to give up hostilities, ill will or aggression in return. It is a natural process that everyone experiences in the presence of a truly non-violent person. Relational-cultural therapy (RCT) - established by mental health professionals - uses the above-mentioned tools to nurture and sustain healthy relationships.

Among other interventional modalities, yoga could very well be helpful in making interpersonal relationships healthy, nurturing and strong. Not surprisingly, a recent research study entitled “I am a Nice Person When I Do Yoga: A Qualitative Analysis of How Yoga Affects Relationships” concludes that yoga improves and sustains interpersonal relationships as it makes the practitioners more patient, kind, mindful, and self-aware. In the study published in the Journal of Holistic Nursing, Ross, et al used content analysis (data drawn from verbal, print, or electronic communications are analyzed for the purpose of condensing, describing, and ultimately categorizing specific phenomenon) on a large cross-sectional anonymous survey of yoga practitioners (N = 1,067). After using suitable inclusion and exclusion criteria, 4,300 yoga practitioners were randomly selected from all major regions of the country. All of them received an online survey asking detailed questions about their yoga practice, health status, dietary habits, illness and relationship status. In addition to attributing yoga to a healthy dietary status and perfect health, 67% of the practitioners agreed or strongly agreed that yoga improved their inter-personal relationships as well.

The major conclusions drawn from this content analysis study were:

• Yoga leads to personal transformation by cultivating several psychological traits, including insight, self-awareness, mindfulness, calmness, peacefulness, happiness, kindness, tolerance, respect, and compassion.
• Yoga increases social interaction and decreases feelings of social isolation.
• Yoga provides coping mechanisms to weather relationship difficulties and losses.
• Yoga leads to spiritual transcendence and connection.

Based on the answers and final analysis, the authors concluded, “Because social support is an important predictor of morbidity and mortality and yoga practice contributes to social support, yoga could be beneficial for populations at risk for social isolation, such as those who are elderly, bereaved, or depressed as well as individuals undergoing interpersonal crises.”

The above scientific study is definitely an eye-opener and I would encourage everyone to read this wonderful piece of science. Now if I have to heal the wounds of my relationships, I do not need to go far. My yoga mat and the practice from it will serve as the balm!!

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Rectal Pain and Yoga (Proctalgia Fugax and Levator Ani Syndrome)

by Baxter

I received this email a while back, and at first I thought someone was pulling my leg!

"I have a family member who was recently diagnosed with Proctalgia fugax. I was wondering if you could tell me if there are any ways that yoga can support preventing and dealing with flare ups of this."

You see, because "proctalgia fuguax" means pain in the rectal area, I read this as “I have a family member who is a pain in the rear….” But then I realized it was not “is” but “has”! Proctalgia fugax (PF) is a condition of pain in the rectal area that you might not think is super common (there might be some reluctance for many patients to come forward with the condition due to embarrassment) but it turns out the prevalence ranges from 6-18% of the population of the developed world. And a very unwelcome guest it is when someone develops it.

The posterior aspect of the rectum exposed
by removing the lower part of the sacrum
and the coccyx

The presence of pain in the rectal area that is not related to more serious underlying issues can be PF or its related condition, Levator Ani (one of the pelvic floor muscles) Syndrome (LAS). The two conditions are very similar in presentation, but the pain with LAS can last up to 20 minutes, where the pain in PF is usually seconds to minutes. LAS pain can be more dull and lingering, and is experienced higher in the rectum, whereas PF pain is sharp, intense, sudden cramping pain in the anus or lower rectum.  Really severe episodes of either can have syncope (or fainting) arise, which can have obvious unwanted consequences—can you say falling and breaking something? Sometimes patients find that having a bowel movement can relieve the pain.

The underlying cause is not clear, although spasm of the pelvic floor muscles is at the top of the list of possibilities. There is a theory that there is some connection to Irritable Bowel Syndrome, and high levels of stress also seem to aggravate PF and LAS, just like IBS. Episodes of pain can happen both day and night, and since the symptoms don’t last very long, most western pharmaceutical treatments to treat the pain once it arises are not very effective.

Patients with PF or LAS will have unpredictable, episodic pain. It can start in a person’s teen years, but often appears during adulthood, the average of onset being 45. More women than men report it, but that may be because women actually report things to their doc. Come on, fellas—fess up!  And because there could be another more serious condition causing pain in the rectal and anal area, it is important to have a visit to your doctor to rule out more serious and potentially life-threatening conditions. Once that is done, you can feel more reassured that this is ultimately a benign condition, but one you may be able to improve with yoga tools.

Just as IBS has been found to improve with regular yoga practices, I think PF may also. There is no formal research on this, so your family member can study his/her own symptoms and see if the yoga practices lower the frequency, intensity and duration of pain episodes. As is almost always the case, start with gentle, beginning-level poses, and add in simple quieting pranayama practices and meditations that promote deep physical and mental relaxation.  From there, you could see what effect adding the practice of simple inversions like Downward-Facing Dog, Legs Up the Wall (Viparita Karani) with the hips elevated, and Supported Bridge Pose on a block, will have on the PF symptoms. I postulate that the inversions will decrease the blood pressure and general pressure from the pelvic floor, which could have a beneficial effect on the PF course. 

According to the Columbia University’s Health website’s Q&A pages:

"The most common treatment for Proctalgia fugax is simply to push on or massage the anal area or the perineum. This may be done manually, or by straddling the edge of an empty bathtub (carefully) or sitting on a tennis ball."

And an old research report from 1961 mentioned that several members of a family that had several generations of family members who had PF symptoms would sit with the heel for one foot under the perineum when pain struck, and it seemed to relieve the pain. This sounds like the foot position taught in the Iyengar tradition for some of the seated poses like Ardha Matsyendrasana. The heel in the perineum is also mentioned in the earliest books on hatha yoga, not to relieve pain but to influence prana in the body. How intriguing that it could also relieve pain! Might be worth practicing this when the pain strikes. 

Since this is relatively uncharted territory as far as yoga’s influence of Proctalgia fugax goes, please let us know if introducing yoga has some effect on your relatives PF! For more details on PF and LAS, check out this website about proctalgia and rectal pain from the UK.

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