Join the Women's Health Online Training

Learn More

Most Popular Articles

Month: December 2019

Self Care in Healthcare

By Leah Deutsch for Yoga Medicine®.

As a doctor of obstetrics and gynecology, I took a rather unconventional path to arrive at my healthcare profession. In the UK, the traditional route to a medical degree is a 5-6 year track, however, I diverged from that track with a bachelors degree in law, international travel, and serving on a child protection team before embarking on a graduate entry medical degree. Despite this meandering path, I always knew I wanted to work in obstetrics and gynecology (O&G) because it’s an incredibly diverse specialty where you need the deductive skills of a medic combined with the technical prowess of a surgeon. Add to that a thrill seeking behavior of an adrenaline junkie and you have the perfect O&G doctor!

Acclimating to Stress in the Medical Profession

Although I took time to ensure I was ready to commit to this career path, I wasn’t prepared for the magnitude of stress encountered in each day. The thing that you don’t really realize until you are thigh deep is while caring for a generally young and healthy population, anyone can become life threateningly unwell at a moment’s notice. The increasing seniority in women’s care further increases the amount of personal responsibility laid on the shoulders of an O&G doctor. When you add in the impact on personal health, such as the increased risk of breast, gastrointestinal, and prostate cancers 1 from working night shifts and a chronically understaffed system, it sometimes makes you wonder why anyone chooses this career! Don’t get me wrong — when the outcomes are positive it is one of the most rewarding and privileged jobs to have. It’s moments when you are faced with a mum or baby dying or having life-changing outcomes that accumulatively take their toll on a doctor’s mental and physical health.

A Pathway to Burnout

My own journey in O&G involved a few rather traumatic events during the first three years. In my first year, I was involved in two maternal deaths and an intrapartum still birth (babies dying prior to labor is about 3.74 in 1000, while in labor is far rarer around 0.32 in 1000). 4 Sadly, these events are arguably more common than necessary in the developed world. These are healthy women who come into the hospital but either they or their baby died from complications in labor.

During my second year of training, a baby died following a caesarean section I performed. I can still close my eyes and remember trying to hold it together, while suturing the woman’s shaking abdomen as she sobbed beneath me. The case went to the Coroner’s Court and I spent most of my third year of training waiting for my day in court. The verdict was that the medical team was not at fault, but the year of stress and worry had already taken its toll on me. By my fourth year of training, I was waking in the middle of the night, unable to sleep and dreading work. I began to experience a complete lack of connection and in some cases, resentment towards my patients. I had nothing left for the people close to me in my life. I was suffering from burnout.

PTSD within Obstetrics and Gynecology

In my field we have a 30% attrition rate. These are not young and disillusioned medical students having a change of heart, but rather professionals who could be 7-8 years into their careers that ultimately decide their livelihoods are unsustainable.

Professor Pauline Slade from the University of Liverpool has done extensive research into the burnout of healthcare workers. 2 In her 2019 study forthcoming in the British Medical Journal, Professor Slade identified that 1 in 10 O&G doctors suffer from clinical symptoms of PTSD and 1 in 5 from subclinical symptoms. 3 When I first heard that statistic, I needed a moment to let it sink in. I felt a mix of utter sadness that such an incredible percentage of my colleagues are suffering and also experiencing a feeling of inevitability; somehow I was unsurprised given my own experience. I realized this was not ‘feeling a bit stressed’ — this is PTSD!

A Path to Yoga

I first discovered yoga in 2001, though it was not a significant part of my life at that juncture. During medical school yoga grew in prominence as a handy relief from academic stress; but like many, my initial focus was largely on the physical practice. There was no one light bulb moment for me, but a gradual understanding of the deeper self-connection I gained by stepping on the mat. I slowly immersed myself further, not really knowing why but realizing it served to replenish my depleted self.

As I embarked on my career in O&G and began to experience these early symptoms of burnout, I found myself turning more frequently to my yoga practice. It was a kind of lifeline, a moment where I could focus inwards to who I was away from my role as a caregiver and doctor. Eventually, yoga permitted me to cultivate a stillness and a connection to being present for the first time. It didn’t remove the environment I had to work in, but it did create a kind of pause button. It enabled me to see what was important and I started to notice that I was able to curate these moments of presence away from the mat too. I found myself using pranayama and mindfulness techniques while caring for women in labor and I slowly rediscovered a passion in caring for these patients. Incredibly, I found that I began to feel less drained and even more energized with feelings of positivity from being able to connect with my patients when I took a more holistic approach to their care.

Yoga as a Tool for Lifelong Learning

In 2014, I decided to embark on a yoga teacher training due to the inspiration from what I saw yoga was bringing to both my patients and myself. Always the scientist, I felt compelled to understand what was going on at a deeper level with my practice. This was to be something purely for my own personal growth and development, but it ended up shifting my entire perspective. On my return, from a 3-week intensive training, I took steps to negotiate a reduction in my hours at the hospital, meaning I had one day a week, which was reserved entirely for yoga.

Subsequent trainings over the past five years in prenatal yoga, pranayama, and meditation have led to a continued and hopefully life long enquiry in to my practice, widening my focus to include these more subtle benefits alongside my physical yoga practice. By teaching prenatal yoga, I have gained a great personal reward in bringing these tools to women in my community which supplements their care in a very different way than in my role as a doctor.

East Meets West – Addressing the Issues

Historically, the culture fostered by the medical profession has embraced almost a militant-like detachment. Admittedly, this mental functionality serves a valid purpose in the heat of an emergency; however, it does medical professionals a disservice when processing these very real and often traumatic experiences that can manifest into burnout and high attrition rates. In recent years, there has been a gradual movement to support the wellbeing of healthcare workers and a recognition that this antiquated ‘tough it out’ mentality needs to be reworked.

The fact that yoga encompasses moving, breathing, and ‘being’ in a mindful way means to me that yoga is accessible to so many regardless of physical capacities. The use of yoga’s mindfulness tools that activate the parasympathetic nervous system and ease the mind-body disconnect can potentially provide a cheap and accessible source of healing.

Doctors are beginning to advocate for a fundamental change in how we support each other. This is reinforced by research confirming what as health care professionals we already experientially know. A 2018 randomized controlled trial showed a significant reduction in depression, anxiety, and perceived stress scores (63%, 58%, 40% respectively) in workers practicing mindfulness based techniques. 5 These scores were maintained in 3 and 6 months follow ups.

My own personal experience echoes these findings and I know anecdotally that many others feel the same. It is an exciting area of change and I passionately believe that by acknowledging the relevance of this ancient practice in treating modern day symptomatology, we could create a more resilient and compassionate medical workforce. As a society there needs to be more of a discussion in remedying a culture responsible for decades of damage and a shift to caring for the care takers.

References

1. IARC Monographs Vol 124 group. Carcinogenicity of night shift work. Lancet Oncol 2019; 20: 1058–59.
2. A programme for the prevention of post-traumatic stress disorder in midwifery (POPPY): indications of effectiveness from a feasibility study Slade, P, Sheen, KS, Collinge, S, Butters, J and Spiby, H (2018) A programme for the prevention of post-traumatic stress disorder in midwifery (POPPY): indications of effectiveness from a feasibility study. European Journal of Psychotraumatology, 9. ISSN 2000-8198
3. The implications of traumatic work-related perinatal experiences for obstetricians and gynaecologists: findings from the INDIGO study. Paper presented to World Congress of Obstetricians and Gynaecologists June 2019 Professor Pauline Slade, Institute of Health and Life Sciences, University of Liverpool
4. Healthcare Quality Improvement Partnership (2018) MBRRACE-UK Perinatal Mortality Surveillance Report 2018. Available from: https://www.hqip.org.uk/resource/mbrrace-uk-perinatal-mortality-surveillancereport-2018
5. The Effects of an Online Mindfulness Intervention on Perceived Stress, Depression and Anxiety in a Non-clinical Sample: A Randomised Waitlist Control Trial, D Querstret, M Cropley, C Fife-Schaw INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE 23, S54-S55

Understanding How Physical Changes That Accumulate With Age Impact The Practice Needs Of Older Students

By Ashley Bouzis for Yoga Medicine®.

“A human being would certainly not grow to be 70 or 80 years old if this longevity had no meaning for the species to which he belongs. The afternoon of human life must also have a significance of its own and cannot be merely a pitiful appendage to life’s morning.” — Carl Jung

According to the US Census Bureau, the number of Americans ages 65 and older is projected to nearly double from 52 million in 2018 to 95 million by 2060. With this, the 65-and-older age group’s share of the total population will rise from 16% to 23%. 1 We can anticipate this shift in population demographics will be reflected on the mats of yoga students. In fact, the 2016 Yoga in America Study reports that nearly 40% of practicing yogis are over the age of 50. 2 These older individuals are more likely to have previous injuries, mobility restrictions and alterations in neuromuscular function than their younger counterparts.

Following, we explore some of the changes that occur in the pelvis, spine, joint capsule and neurologic function throughout the lifespan and I outline some tips and tricks to keep in mind when working with older yogis to assist in creating a safe practice that honors their needs.

The Pelvis and Lumbar Spine

In older populations, we often find shortened, high-tone hip flexors, particularly in individuals who spend a significant amount of time in a hip-flexed seated position. With this hypertonicity and shortening of hip flexors, the pelvis is pulled into a tipped forward position and the lumbar portion of the spine assumes a hyperlordotic (swayback) curve. This orientation of the pelvis allows a fair amount of mobility but is not structurally ideal as it increases risk of disc rupture and pinching of neurovascular bundles as they exit the spinal column. Additionally, it may contribute to low back pain as the surrounding musculature attempts to bring the spine into alignment.

A posteriorly tilted pelvis (which can also be brought on by prolonged sitting) is generally accompanied by gluteal muscle clenching and/or abdominal gripping; compensatory changes that take over as the body attempts to accommodate for the center of gravity shift caused by the posterior tilt. To get a sense of what this feels like, stand and squeeze your glutes together as if trying to bring your pubic bone forward and up. At the same time, turn on your abdominals as though trying to bring your anterior lower ribs in contact with your anterior superior iliac spine (ASIS). Now try to move around. You’re pretty locked in, right? Imagine trying to do a sun salutation from that position! Not only does this position limit mobility, it can also result in pinching or compression of the sacroiliac (SI) joints; another known contributor to low back pain.

So, if we don’t want our pelvis tipping too far anteriorly or too far posteriorly, where on earth is it supposed to be? I’m guessing you’ve heard of the “neutral pelvis,” right? Well, that’s what we are aiming for, but with a few tweaks!

When finding “neutral pelvis,” many of us have been taught to cue students to direct the ASIS toward the front of the room or bring the pubic bone slightly up. The challenge with this cue is it doesn’t accommodate for the fact that each person has an individually specific pelvic angle that allows their spine and pelvis to align in a way that maximizes stability and shock absorption. For this reason, the cueing described above will create the correct position for some students, but place others outside of the most “functional” range of their pelvis.

I find the most accessible way to find a “functional” rather than “neutral” pelvis is to instruct students to bend their knees slightly and gently bounce up and down, taking note of where the pelvis naturally wants to lie. The slight bouncing relaxes the tightened hip and gluteal musculature helping to allow the pelvis to fall into its functional position. The sensation we want students to find is that which allows an equal balance of support on all sides of the low spine without feeling excessively elongated or pinched in any one area. Once students feel they’ve found this position, invite them to slowly back out of the knee bend towards a straight leg position while maintaining the pelvic angle. As they straighten their legs, they should find their core naturally activates. Many students will find their center of gravity shifts slightly backward so the hips line up more directly over the ankles – the start of a great Tadasana (Mountain Pose). While assuming this position, I find it useful to remind students to not allow the glutes to take over and to only straighten the legs as far as they are able without letting the pelvis fall out of the established functional position. Keeping a micro-bend at the knee often helps with this.

The Mid Spine

Next, let’s turn our eyes to structures further above the pelvis, notably the changes that accumulate in the mid and upper back as we age.

Over the course of a lifetime, the human body experiences an overall reduction in bone mass. In the spine, this results in a decline of mechanical strength and collapse of the anterior and central portions of the vertebra. As these changes accumulate, one may experience pain, loss of height, and loss of the normal curve of the thoracic spine resulting in a hump or kyphosis. These changes occur alongside weakening of the structural integrity of intervertebral discs, which provide cushioning between the vertebral bodies. When the structural integrity of the disc is compromised, disk rupture and herniation become more likely. Rupture or herniation of disc structures may compress motor and sensory nerves as they enter/exit the spinal canal. If structures are compressed enough, radicular (shooting) pain or decreased muscle strength may develop.

Because much of the reduction in bone mass (mechanical support) is beyond our control, we need to look to other ways of supporting the spine as we age. The primary muscles of support for the spine are those of the deep back and core. Assisting students in building awareness and activation of these muscle groups helps protect the integrity of the spine through muscular support as mechanical support declines.

In addition to standard reclined core activation exercises, moving the body through leaning exercises while standing can help students develop the muscle awareness necessary to keep the core active as they move. To do this, I start with functional pelvic position as above and then ask students to gently and slowly lean forward, to the side, and slightly back while being mindful to keep the core active and the glutes relaxed. Many students will find a tendency, particularly as they lean backward, to almost “crunch” which brings the pelvis and chest forward in an effort to offset the center of gravity. The goal is to avoid these types of compensatory movements by only leaning as far as one can while maintaining the normal curvatures of the spine.

Bhujangasana (cobra) in a chair can also be used to activate and strengthen the upper back muscles. From a seated position, invite students to place their hands behind their head or use a strap if bringing the hands together is uncomfortable. Keeping the pelvis and neck in neutral range, ask students to look upwards on the wall towards the ceiling while maintaining the focus on moving from the thoracic spine as opposed to the lumbar or cervical spine. To incorporate more opening of the chest, students may place their hands behind them on the chair or out to the side in a wing-like position. If adopting these variations, it is important not to arch the neck too far backward. Keeping a subtle tuck of the chin can help offset this tendency.

Changes to Range of Motion

Studies show that our bodies experience a decrease in range of motion of multiple joints as we age. 3 While the exact mechanism of this decline remains poorly understood, the leading theory is that with age, the connective tissues responsible for joint stability (tendons, ligaments, and the fibrous joint capsule) undergo naturally occurring declines in compliance leading to restriction of mobility. In addition to the loss of tissue compliance, decreased range of motion (ROM) is exacerbated by reductions in bone mass, painful arthritic changes, alterations in muscle strength and injuries that accumulate over a lifetime.

While impaired range of motion in any joint will contribute to pain and functional impairment, mobility of the hip and ankle joints warrant specific attention as they contribute most significantly to back pain, gait (walking) abnormalities, and risk of falling.

Kapotasana (Pigeon) and Virabhadrasana I (Warrior I) are both wonderful poses to address mobility of the hip. As floor work may not be accessible for all elderly students, both poses can easily be adapted to a chair.

In seated Warrior I, students are asked to sit sideways in a chair with the seat supporting one thigh and the same side buttock. The leg to the outer part of the chair is then slid around to the back and the leg straightened as much as is comfortable. Because the chair supports the weight in this pose, more focus is directed to the stretch of the hip flexor as opposed to building strength in the lower limbs. If one wants to play with building strength from this position, simply engage the muscles required to lift the thigh away from the chair.

For seated Pigeon, one ankle is placed on the opposite knee to achieve lengthening of the external rotators of the hip. If more intensity is desired, students may lean forward, taking note to lean from the pelvis and to avoid rounding the lower back.

Working on ankle mobility is also easily accessible from the seated position. Controlled articular rotation exercises (CARs) offer a way to increase both range of motion and strength of the muscles responsible for ankle dorsiflexion (the motion that clears the foot over the ground during walking) and plantar flexion (necessary for the push off phase of walking).

To perform an ankle CAR from a seated position, ask students to extend one leg until the back of the heel rests on the ground. From this position, slowly move the foot into maximum plantar flexion, then slowly rotate the foot in a circle reaching to the end of the available range in all planes. The benefit of this type of movement is that it moves the joint through its “usable” range of motion under muscular and neurological control which enhances length, strength and control as opposed to utilizing passive stretching which only lengthens tissues. CARs can be used for nearly every joint in the body. There are a number of online resources illustrating how to apply CARs movement to various joints.

Proprioception

Another known change with age is a decline in a sensory function known as proprioception (the joint-position sense we use for balance and knowing where our body parts are in space). Declines in this sense contribute significantly to fall risk. While many of the treatments proven to improve proprioception are outside of the scope of a yoga practice, “active movement training with visual input” is a technique that can be applied on the mat and has been found to be one of the most effective ways to train and improve proprioception. 4

To engage in active movement training, students are asked to identify a target on the ground or wall and to use their visual input to guide a given body part to touch the target. For example, you might ask students to start from a standing position with arms at their sides and identify a small, distinct area on the floor, maybe a crack or an area of unevenness in the texture. Once the area is identified, you invite them to reach an identified body part (i.e. the heel) to touch the area and then bring the heel back to its previous position. For students with visual impairments, the instructor can provide verbal feedback to assist in reaching the target. When utilizing targets on the floor, it is best to start with flat targets (i.e. a mark or piece of tape on the floor) and utilize elevated targets (i.e. a block) only if the student has adequate strength and balance.

The Mind and Soul

In late adulthood and beyond, individuals often define their lives by what they are contributing to the world and what legacy they will leave behind. Psychoanalyst Erik Erikson referred to the final stages of life as characterized by generativity versus stagnation and ego integrity versus despair.

During the mid-stages of late life (approximately age 40-65), individuals may find themselves reflecting on their sense of “needed-ness.” Relevant questions may include: Am I contributing enough? To whom do I matter? How can I improve the state of the world? If one does not perceive that they will leave a legacy in line with their values, they may feel a loss of inertia and purpose. Encouragement to reflect on the legacy one would like to leave and ponder ways of building that legacy can be welcome class themes for students at this stage.

Beyond the age of 65, individuals often begin to contemplate the mark they will leave on the world at the time of their death. Relevant questions at this time include: Did I do enough? Have I acted in ways that reflect my values? What regrets do I have? At this stage, it is quite normal to experience a sense of regret and despair over prior actions. In order to peacefully conclude this, it is helpful for individuals to accept that there are aspects of their life they find regrettable and also aspects they find pride and peace in. Acceptance of this dialectic may help individuals develop the “sense of coherence and wholeness” 5 that comes from the “acceptance of one’s one and only life cycle as something that had to be.” 6 At this stage, students may benefit from themes surrounding the acceptance and tolerance of emotions such as regret, an opportunity to reflect on what parts of their legacy bring them a sense of satisfaction and encouragement to resolve any relationship rifts they feel able to.

Conclusion

As teachers, we are given the opportunity to work with students of all demographics, including those whose bodies have seen them through the morning of life, into the afternoon and beyond. Understanding the changes that occur as the body and mind move through these stages allows us to create a safe, effective and respectful practice for yogis of advanced age.

REFERENCES
1) Projected Age Groups and Sex Composition of the Population: Main Projections Series for the United States, 2017-2060. U.S. Census Bureau, Population Division: Washington, DC.
2) Ipsos. (2016). “2016 Yoga In America Study.” Oct 7-16, 2015. Retrieved from: https://www.yogaalliance.org/Portals/0/2016%20Yoga%20in%20America%20Study%20RESULTS.pdf
3) Stathokostas, L., McDonald, M. W., Little, R. and Paterson, D.H. (2013). Flexibility of older adults aged 55–86 years and the influence of physical activity. Journal of Aging Research, 2013, 743843.
4) Aman, J.E., Elangovan, N., Yeh, I., Konczak, J. (2014). The Effectiveness of proprioceptive training for improving motor function: a systematic review. Frontiers In Human Neuroscience, 8(1075).
5) Erikson, E. (1982). The life cycle completed. New York, NY, US: W W Norton & Co.
6) Erikson, E. H. (1950). Childhood and society. New York, NY, US: W W Norton & Co.

Mastering the Business of Yoga Podcast Interview: Tiffany Cruikshank on Creating and Growing a Successful Yoga Business

Amanda Kingsmith interviews Tiffany Cruikshank for the Mastering the Business of Yoga Podcast.

On this episode of the podcast, Tiffany talks about how she has worked to combine the eastern and western models of medicine to help serve her clients, how she has expanded her business from just in-person work to online courses and programs, as well as training programs around the world. She also talks about the Seva Foundation that she has founded, and all of the business lessons she’s learned throughout her career!

Click here to listen to the full episode and to download the podcast here. Also check out the podcast on Facebook and Instagram.

Join The Yoga Medicine® Community

Subscribe to our newsletter to stay up to date with
our latest trainings and resources.

Yoga Medicine
Scroll to Top

Find Out More