The role of yoga in patient care
Dr Krishna Raman
This is a vast and a new subject for us doctors who are trained in western medicine but yoga has been existing for centuries in India. It was part of the people's daily life style to ensure physiological fitness so that therapy was not needed. Later as man's life style changed to an indiscplined style one, diseases increased and the need for "yoga therapy" arose.
Yoga has many connotations. We as doctors should be concerned with the physical discpline of the subject to see if it can offer tools of treatment in mainstream medicine.The physical discipline of yoga consists of many asanas or postures which have specific geometric shapes.
This when executed produces certain,physiological changes in the body. This is often misintrepeted as mere relaxation. There is more to it than this.How does one understand the role of yoga in patient care unless one knows the properties of asanas ?.
This is understood only if one has done yoga. Yoga is a kind of exercise but with salient differences from others. To highlight this, I have summarised below the effects on different organs systems in comparison to the usual concept of exercise.
What is important to understand is that yoga is like food. If one eats, hunger is appeased. The effects of yoga are like this and can shown to be so. One therefore does not need to try to use statistics in yoga as it is a natural system. The human body cannot be be channelised in any manner of behaviour as far as yoga is converned.The effects of placebo can be ruled as each pose has a specific effect which is so obvious.
Unless one has studied yoga one cannot analyse the subject as the way in which it works is totally different and one cannot use the same yardstick to understand it as we do for western medicine. Sure enough, the effects can be studied to a great extent but one must know what is happening as on executes the asana before one can analyse it.
For example in performing an asana. There are several parameters to be observed if one wants to demonstrate the optimum effect on the human body. Considering Supta Virasana illustrated below- the following are to be analysed :
Are both the heels taking equal strain? Are all the extensor tendons of the dorsum of the foot sretched equally? Are both the buttock bones resting equally on the ground? Is the navel in the center? Is the sternum kept parallel to the ground? Are both the knees rolling inwards equally-(this makes sure that the cartilages inside are in alignment)? Are the quadriceps kept parallel to the ground?Is the groin rolling inwards or outwards? Is the lumbar or thoracic feeling the strain? And so on.
The same pose done by a fat person will have different effects on different areas if these parameters are not followed properly. In order to get the right effect the same person has to be taught the corrrect method to get the same effect as one would expect in a person of optimum weight. This has to be applied to all human beings of different shapes and sizes. Unless one knows the ideal effect of the asana on cannot devise studies to apply the properties. The results would vary. Then conflicting studies have no value.
Once a radiologist wanted to study if the vertebrae of those who practice yoga regularly were different from the rest of the population. But this is very difficult to analyse as there are different body shapes and sizes and one has to make sure that all are doing the pose properly. This being the case we cannot theorise about yoga at all.A thin person doing a twisting pose will feel have no effect at all as the torsional effect will not be felt.
A fat person will have to strain to get the pose right. So one has to select the subjects carefully and analyse.The thin person wll get better benefit from advanced poses and the fat person from simple poses. So, one has to be a student of the science before analysing it . But very often we try to analyse it with our western medical training which is an incomplete approach to learning the subject of yoga.
The above illustration is to show the fact that even at such an age one can maintain excellent fitness. The pose at first sight looks impossible. But with careful understanding of joint movements one can achieve this. Today Bks Iyengar is the only person at 79 yrs of age who can still perform yoga as he did as a child of 14.
The system of yoga taught by Sri Bks Iyengar has popularly come to be known in the west as "Iyengar Yoga". There is a distinct difference between this and other systems which places his teachings far above everything else. This is partiuclarly when one analyses his methods medically. Medically, when the human body is used in exercise particularly yoga, care has to be taken to use the internal and external organs properly.
In most yoga schools, there is no depth to the teaching of yoga as can be seen if one happens to be a physician. Secondly this system can be used in mainstream medicine to solve major medical problems where other systems have failed. I have studied different systems and have found that there is a lack of anatomical guidelines in the execution of asanas and pranayama.
To illustrate this I will give several examples. In standing poses, for eg:trikonasana ( see Light on Yoga- Iyengar , Bks, Allen and Unwin Paperbacks) if one observes students trained in other systems, there is no arithmetrical and geometrical perfection and certain areas are ill affected. Again in headstand, there is no guideline in other systems as to how to prevent pressure on the brain due to the increase in blood flow whereas in iyengar yoga learns to adjust the blood flow in such a way so as to give the correct effect inside. This can easily be seen by a transcranial doppler.
The frontal and back brain has to be kept parallel in order to ensure proper and optimum blood flow and relaxation of the neurons of the brain. Unless one does the different systems it is difficult to understand the inherent problems of other schools of yoga. Generally yoga is done slowly and with a lot of stretching but there is no strength in the stretch and contraction is totally forgotten. More over I have seen any number of patients coming to me with no relief from other systems and when the protocols are followed relief results very fast.
Any exercise has to strengthen , tone up the system and preserve the body as one grows older. To achieve this the different parameters of the body need to be observed to find out if they are used to optimum. As a medical professional I find that only iyengar yoga achieves this. In this system the body is made robust both outside and inside.
A good example is practicing backbends which provide vitality to the system. In Iyengar Yoga,one insists on a certain geometric shape of the asana which alone provides cardio-respiratory health whereas in other systems one can observe incorrect shapes and the practitioners suffering ill health later on. For example in Urdhva Dhanurasana (see light on on yoga), medically ,only at a particular angle of the dorsal spine does the heart pump efficiently, . This is logical as certain angles compress the heart. The correct angle is taught in the Iyengar system.
The skin on the front and back of the body have to be kept at the same distance- parallel to each other. The pelvic girdle should not collapse which then results in compression of the pelvic organs.
First of all the concept of whether or not geometry of asanas is needed or not is not at all thought of by all other schools of yoga. Subtelities of yogic practice are available only in the iyengar system .The test comes when they suffer pain or disease in spite of practicing yoga or secure no relief in spite of yoga and the moment they learn the correct method, relief results.
I myself suffered severe backaches even though I practiced yoga and no school of thought gave me relief. For years I suffered. Stretching the spine in a different way than what I was to, was taught by iyengar . This immediately provided an immense change. This made me to realize that there is much more to yoga than generally understood. And this provoked my interest. This cannot be appreciated by lay persons unless one knows anatomy. In iyengar yoga instructions are given on how to strengthen tendons, arteries veins,bones,organs etc.
The mind is brought to focus on different areas of the body for correct adjustment. In other systems, breathing is taught instead and this is medically harmful. Unless the lungs can expand perfectly in a particular asana, breathing should not be performed. This is a very vital medical tenet. For a beginner the breath is shaky and when asanas are done with shaky breathing ,ill health results.
The breath in an asana is taken from the superficial to the subterranean plane to ventilate the cells of the body and this is achieved only if the relevant areas of the body can open up to the breath. This means proper perfomance of asanas .
In the hatha yoga pradipika a classic text of yoga, it is said that the mind is the king of the senses and the breath is the king of the mind. Calm the breath and the mind is quiet . This should be carefully followed . When one medically examines persons trained in other schools , their body parameters lag far behind when compared to students trained in the iyengar system.
The perfomance of asanas creates a certain space between the spindles of the nerves and skin resulting in profound neurological relaxation. This happens only if every part of the body is put to use .
I have already spoken about the standing and inverted poses. Coming to the forward bends- if the diaphgram is not kept parallel to the floor the heart is compressed. If the antereo-posterior diameter is altered, the thoracic organs are pressurised .
In twisting poses , the inner and outer spine have to be kept in alignment else the spine is not used symmetrically. The chest should be kept as erect as possible.
In balancing poses ( see bakasana below) the mind is to be kept calm which means the front and back portions of the body have to kept like the scales of a balance and one should distribute the body weight in such a way that the pose is arithmetically balanced. Balancing poses therefore mean a balanced action of the body and mind in the asana and not with heavy tension in retaining the pose.
Like this, there are many tenets for each pose which have to be followed for the body to benefit.. Then as patanjali , (who is considered as the father of yoga )says -"stira sukham asanam"- the posture is pleasant, comfortable and easy.
The aim of yoga is "sammatwam yoga uchathe" .Yoga should bring in the body and mind a eveness of the physical, mental emotional and psychological parts of our being. The asanas and pranayama should be done in such a way . The cells of the body have to be balanced on each other in a perfect way in each asana.
Western medicine has not adressed many problems in a wholesome manner. We have our faults and unless one is open to it, one will never seek or allow the patient to secure relief with other systems. It is of course important to have a doctor to investigate matters in alternative sciences so that a rational approach can be maintained. But we do not have time nor the interest to study another science . A patient must be offered as far as possible, a non drug, non surgical method of managing problems.
Below , I have summarised the salient differences between yoga and other systems:
Cardiac system
Heart rate not "irritated "
Blood pressure regulated
No adaptive changes in the cardiac muscle
Stimulation is non-irritative
Massaging action -the effect can be seen on an ultrasound where the chamber shape changes in response to different asanas and the effect of certain poses can be felt on the heart
Cardiac ailments benefit .
The last is probably the most important benefit for coronary disease. It may be unsafe for a patient with angina to run on a treadmill but it is very safe to do yoga.
In my experience with such patients I have found that their effort angina improves, and they can carry on normal activities throughout their life. This does not happen in diabetics though. In treating such patients , I continue their drug regimen, till they have done yoga for several months and then taper it and follow them up. So long as they are regular in yoga practice they do not have any recurrence in symptoms.
It is very difficult to explain the effects of some postures in this situation . It is risky to have an angiogram in the posture to explain symptoms. Certain inferences can e given however- the sympathetic nervous system is given enough rest in yoga . The cardiac output is also increased by dilating the thoracic bed in asanas. But this is done wihout an increase in pulse rate or bp.Some of the poses squeeze the heart and this works on the principle of reactive hyperaemia.
Most important of all,backward bending asanas are highly beneficial for angina. They maintain the elasticity of the arota which acts as an axillary pump for the coronary arteries.The action of backbends can be understood when one actually performs them. The following explains the effect of yoga on the circulatory system:
Circulation
Orthostatic tolerance-no change unlike other exercises
Circulation without strain-the effect can be studied with a doppler probe
It is along anatomical lines of the asanas
Automatic massage
No pounding and pulsating actions
Velocity and direction controllable
Respiratory system
No oxygen deficit
Elasticity of cells maintained
Every alveolus attended to
Regulation of sympathetic and parasympathetic
Greater intake of o2 and conservation
Cells not flogged
Elasticity of ribs,intercostal muscles and diaphragm-the elasticity of the diaphgram is given great importance in yoga and is possible only in this science
Blood flow ,ventilation and perfusion maintained
Backbends -special action lungs withstand climate,altitude
Digestive system
Massaging action of asanas-----,rinsing,flushing,soaking ,squeezing and drying are the mechanisms of asanas
Secretions can be increased or decreased
Endocrine glands attended simultaneously in forward bends
Ultrasound reveals some of the actions
Excretory system
No fluid or electrolyte changes unlike other systems
No protein load on the kidney
Kidney massaged -indirect evidence of massage shown by doppler -increased flow velocity in the cortex
Bladder toned up
Intestines massaged,peristaltic activity improved and absorptive capacity toned up
Endocrine system
No depletion of hormones yet system energised
Inverted poses special effects-one can feel the effect only when one does the pose
Nervine and adrenal connections toned
Forward bends dampen the overdrive of the sympathetic nervous system
Nervine system
Yoga refreshes
Mind and adrenal connection energised
Reduction of sympathetic tone
Recuperation from exhaustion -yoga is the only exercise that can be done even with low leves of energy and one can end up feeling fresh
Yoga is non-stressful
Consistency of nerves soft
Control of autonomous system-at the end of pranayama, the pulse rate is reduced to 55 per min (approx) and this kind of training is given day after day
From the above discussion it is evident that we are dealing with a totally different system,the effects of which can be used as a therapy.
The most common area for which yoga can be used is in orthopaedics. Some of the conditions are low back pain,spondylitis with vbi, listhesis (where exercises can retard the progession of the slip)prolapsed disc with nerve root compression, calceneal spur (asanas provide immediate relief for the pain), pirformis sydrome(a particular asana is the "drug of choice"for this).I have used yoga for all these situations and have seen very good clinical results.
For cardiac patients with effort angina,asanas provide very good relief with cardiorespiratory fitness.The younger the patient ,the better the result.Unless the arteries are very badly damaged, one can resort to yoga with or without medication as a first line level of treatment and then surgery if needed. In my experience if yoga practice is resorted to early enough, the results are better in the long run.
Asthmatics or emphysematics do much better in their symptoms with yoga than with drugs alone. Breathing exercises known as pranayama is par excellence to relax the bronch and tone up the alveoli.
For the younger emphysematous patient, asanas provide excellent methods of respiratory fitness that dyspnea occurs only with greater levels of exertion than before. For a bronchitic, inverted asanas and backbends with pranayama provide excellent relief for recurrent episodes of infection . All this is possible only with consistent practice.
In acid peptic situations, after initial treatment with h2 antagonists are over it is common to see patients suffering a chronic dependence on the drug with an acid rebound if it is stopped.Yoga is very useful to control acid reflux and dyspepsia.
Yoga plays a very beneficial role here. Headaches ( i am talking about migraine,cluster headaches,tension types etc)are partly attitudnal, and organic. If the attitudes are grossly unstable and labile, it is difficult to remedy the situation. Everyone has a certain amount of lablility which I would term "the physiological limit".
In these patients yoga can provide excellent relief for headaches regardless of whether it is migraine or cluster headaches and the postures are forwardbends done in a special way. The diaphgram has to be kept relaxed in the postures to ensure nervine relaxation. .
Millions of women suffer from dysmennorhoea.This is totally an avoidable problem if one has yoga as part of a daily lifestyle. In order to decongest the uterus daily (which is the essence of treatment) inverted poses like headstand and shoulderstand are the lynchpin of treatment.It provides relief to all three kinds of menstural pain.
The pain of endometriosis is also relieved provided the patient starts yoga as soon as diagnosis is made.
Locomotor system
Range of movement greater in yoga
Joints,ligaments muscles remain elastic
Rigidity dominates in other systems
No pounding action in yoga -no wear and tear
No chemical fatigue as in other systems
No adaptive muscle changes
Calculated load on bone
Each asana having a geometric shape lays different stresss and strains on the body which is highly beneficial and one can use any pose to increase the strength of the bone in that area due to the multitude of poses that are available . This is of great value to osteoporosis. More over as the pounding action is avoided it is safer than other systems in this situation. Muscles do not hypertrophy in yoga ,yet, they are very tensile and strong enough to lift one s own body weight. see illustration of bakasana- this is not a very difficult pose if one is trained .
Keeping all the above in mind , how can we sumarise the role of yoga in patient care? It is a vast subject, and one must make a beginning somewhere.
Yoga is not a panacea for diseases but yet its scope is very wide. It is non-invasive and hence safe. A combination of western medicince and yoga is logical as one can use the diagnostics of western medicine and then switch systems for treatment whereever possible.
For eg:as in the case of acute low back pain one needs to reduce pain with nsaids and then start yoga for long term management which is more sensible. It is an excellent system of preventive health care and is cost efective.
It can be used in diferent areas - surgical and medical - patient compliance is a must and they must be educated about lifestyle changes for their betterment.
Generally , we medical proessionals do not live the role we propound. If we advice exercises as a tool of therapy we must ourselves exercise every day . Then the patient feels condfident with us.To use this as a tool one must practice asanas so that one can help the patient.
To use yoga in mainstream medicine is a rational concept as the entire patient community can be educated enmasse. Take a group of healthy individuals and make them practice yoga. Screen them before this for clinical parameters . Follow them up for years. This will give a good breakthough for health care. I shall present specific case histories of different ailments treated with both western medicine and yoga or yoga alone.
For sensible health care the human body alone is the investment. In today's scenario with increase in treatment costs, if everone were to practice yoga, doctors could focus their mind on other critical issues.
As a sequel to this writeup, I am following it up with an article called Biodynamics of Yoga which describes the properties of asanas in a little more detail with more photographs.