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Internal Medicine

Leek Soup with Purple Sage: Transition to Spring

By Dr. Amy Sedgwick & Dr. Rashmi Bismark share a delicious spring leek soup recipe. They also discuss what Eastern medicine says about the transition into spring, and what it means for your body.

Spring Leek Soup with Purple Sage

Spring is here in the Northern hemisphere and the green unfolding around us nourishes the soul through our eyes.  Our energy and creativity are arising as we emerge from a more introspective winter phase and move into the active nature of spring.

During this time of year, Chinese medicine emphasizes light and pungent foods such as fresh herbs, garlic, young plants, fresh greens, sprouts and immature wheat or other cereal grasses.  Foods are best cooked for a shorter time but at higher temperatures.

The Ayurvedic tradition of India offers similar wisdom. As the earth thaws from winter, frost turns to dew, and rains abound, the lusciousness of Spring is associated with the kapha dosha – cool, moist, heavy, soft, dense, and stable. Like in Chinese medicine, diets to maintain balance during kapha season encourage foods that are warm, dry, light, pungent, and astringent.

Spring Foods

While you explore ways to nurture equanimity and resilience this Spring, consider bringing awareness to how the foods you are eating impact your vibrancy. Inviting a taste of mindful eating, use meals or snack times as an opportunity to simply observe the effects of various foods on your whole being with full attention and a bit of playful curiosity. What sensations arise in the body? Is there a feeling of lightness or heaviness, a sense of satisfaction or aversion, or maybe no change at all? What emotions and thoughts are triggered? How do these foods nourish you?

We would love to hear your experiences and invite you to share your favorite healthy Spring recipes with our Yoga Medicine community. In the meantime, here is a wonderful spring soup to tap into the essence of this time of year.  Drawn from the amazing cookbook, The Love and Lemons Cookbook, by Jeanine Donofrio and Jack Mathews – the Spring Leek Soup with Purple Sage is a sure winner.

Love & Lemons photo, www.loveandlemons.com

Ingredients:

4 medium leeks

2 teaspoons (10ml) extra-virgin olive oil

2 Yukon Gold potatoes, chopped into 1/2-inch cubes

4 garlic cloves, minced

1/4c loosely packed thyme sprigs, coarsely chopped

11/2 cups cooked cannellini beans, drained and rinsed

1-2 tablespoons fresh lemon juice

1 recipe traditional pesto

Crusty sprouted bread

Sea salt and freshly ground black pepper

Traditional pesto (mix all of these ingredients together in a food processor until smooth):

1/4 cup evoo

2 tablespoons fresh lemon juice

1 clove garlic

2 cups basil

1/2 cups pine nuts

1/4 parmesan cheese (omit if vegan or use a vegan substitute)

Directions:

  1. Slice the white and light green parts of the leek into rings.  Using a strainer, rinse the leeks thoroughly.
  2. Heat the olive oil in a large pot over medium heat.   Add the leeks and a pinch of salt and pepper.  Stir and cook until the leeks begin to soften, about 2 minutes.  Add potatoes and another few generous pinches of salt, and cook until the potatoes begin to soften about 2 minutes.
  3. Add the garlic and sage and continue cooking for 1 more minute.  Now add the vegetable broth and thyme.  Reduce the heat to a simmer and cook until the potatoes are tender, about 18 minutes, adding the cannellini beans during the last 5 minutes of cooking time.
  4. Add the lemon juice, then taste and adjust the seasonings, adding more salt and pepper as desired.
  5. Serve with traditional pesto and crusty sprouted bread on the side.

Additional Authors:

Dr. Rashmi Bismark, MD, MPH, RYT

Rashmi is a US-trained physician, board certified in Preventive Medicine and Public Health. In parallel with conventional medical training, Dr. Bismark has spent the past 15+ years studying various complementary and alternative healing modalities, including ayurveda, energy healing, yoga, and meditation. She is currently in the process of completing RYT-500 training with Yoga Medicine and is receiving mindfulness teacher training through the Oasis Institute, Center for Mindfulness, University of Massachusetts.

To learn more about the Yoga Medicine team, click here.

Dandelion: The Cure Growing in Your Back Yard?

Rebecca Powell-Doherty, PhD shares some uses for the dandelion, dives into the chemistry and breaks down the studies.

Dandelion: A Not So Humble Weed

Head out to the nearest green patch available to you starting around the early days of Spring, and you will, undoubtedly, identify that bright yellow flower that has unceremoniously been labeled a ‘weed’. Wait a bit longer, and the yellow beauties will turn into soft white puffs of seed that children and adults alike love to blow on and spread all around. The bane of those trying to keep a well-manicured lawn, I am of course speaking about that Spring perennial, Taraxacum officinale, or dandelion.

If you’ve read Tiffany Cruikshank’s book, Optimal Health for a Vibrant Life, you may remember that when she discusses the use of herbs, teas, and tinctures, she indicates that keeping it simple with dandelion might be a great way to go (Cruikshank, 2014). There is a myriad of scientific investigation to support such a statement. Additionally, teas and tinctures made from dandelion have been reported for use in liver, spleen, and kidney ailments dating back to the 10th century (Schütz et al, 2006).

The Chemistry of Dandelions

There’s quite a bit of chemistry that breaks down the how’s and why’s of dandelion’s good work. The Schütz article cited here is a great place to start if you want to dig deeper. For those who just want the core info, though, I can safely say that there is study after study that demonstrates the efficacy of dandelion teas and tinctures as being hepatoprotective, mildly diuretic, anti-diabetic, anti-rhematic, and choleretic. For our purposes, though, I’d like to focus on that concept of hepatoprotection and link it somewhat conclusively to the antioxidant properties of this humble but ridiculously useful ‘weed’.

Antioxidants are, as you might already know, compounds or substances that inhibit oxidation of other substrates. They, therefore, protect against oxidative stress. In terms of the human body, oxidative stress is most closely associated with the function of mitochondria, those “powerhouse” organelles you learned about in biology. The production of ATP, the preferred form of cellular energy, uses oxygen in the process, but it also loses electrons in the process here and there, producing reactive oxygen species (ROS). Those compounds go on to oxidize other very stable molecules, therefore causing a fair amount of damage at the cellular level. These kinds of interactions have been linked to all sorts of issues, from aging to cancer.

Antioxidants & the Liver

That said, our bodies have really great mechanisms for dealing with these guys. Our cells have redundant enzyme mechanisms that are antioxidant in their activity and capable of dealing with reactive oxygen species fairly easily. These include enzymes like glutathione peroxidase, catalase, and superoxide dismutase. Our livers have one of the highest concentrations of mitochondria in the body, and therefore, very high concentrations of these enzymes as well.

Generally, a well-functioning liver filters all sorts of things from our bloodstream with ease, from cellular waste by-products to alcohol. However, sometimes even the liver can fall behind and become less effective. It does, however, take a great deal to permanently damage your liver. This is certainly true for individuals who suffer from cirrhosis or other liver diseases, but it can also be true for otherwise healthy people who just aren’t firing on all cylinders. Stress, anxiety, lack of exercise, and dietary issues can all contribute.

Study 1

So, if we find ourselves in that position, science and history both tell us that incorporating dandelion into our diets is a great way to give our livers a bit of support. A study in Food and Chemical Toxicology (You et al, 2010) examined the role of ‘aqueous extract’ from T. officinale on alcohol-induced oxidative stress. The study extracted dandelion root in both ethanol (a tincture) and water (a tea). In both cases,  pre-treatment with the dandelion extract protected hepatic (liver) cells from oxidative damage.

It is worth noting that the tincture produced more robust results than the tea, but both demonstrated benefit in reduction of ROS in cells, improved cell viability, and protection of antioxidant enzyme levels in the liver. The study was conducted using a pre-treatment approach, so it suggests that incorporation of teas or tinctures into one’s diet regimen should be done consistently and not in the hopes of alleviating damage that has already occurred. That’s not to say damage can’t be undone; the liver is a remarkable organ for regeneration, but certainly prevention and mild injury are easier things to address.

Study 2

A second study, appearing in the same journal (Gargouri et al, 2012), examines how dandelion mitigates damage associated with lead poisoning in neonates. So, while alcohol goes straight to our livers; lead more readily affects our brains and, specifically, the development of young brains. While I mentioned we would focus on the hepatic protection component of dandelion, it makes sense to link antioxidant activity to other organs that also have high concentrations of mitochondria, and our brains most certainly qualify! In this case, rather than testing teas and tinctures, the researchers decided to explore what simply adding raw dandelion or spirulina to the diet of pregnant rats could accomplish.

Remarkably, doing so improved the weight of lead-poisoned neonates back to control levels at birth. It also significantly reduced peroxidation levels (damage by ROS) in the brain and cerebellum of those neonates (more so in male offspring), and restored brain protein levels in offspring to control levels. The effects were also observable in the levels of antioxidant enzymes, restoring them to control levels in every instance. This study was conducted during gestation of the rat neonates and through 14 days postpartum. This points to the power of both herbs to mitigate the damage of lead poisoning during gestation, and more excitingly, during lactation.

Conclusions

The studies we discuss here are really the tip of the iceberg when it comes to the amazing powers of dandelion. They speak to how different preparations can slightly alter the efficacy of the herb. They also suggest that there’s no need to get fancy about how you decide to consume it if you choose to do so. Teas and tinctures are very effective, but so is tossing it, washed and clean, onto your salad now and again.

Certainly, eating it means you need to consume more of it to achieve that same concentrated therapy, but don’t we all need more greens in our life?! As always, you should add any sort of supplement or herb to your regimen after a chat with your doctor. It is important to remember that herbs absolutely count as medicine. Once you get the go-ahead, head back out to the yard (pesticide and lime-free) and enjoy what nature offers up so freely and abundantly.

Other articles by Rebecca Powell-Doherty:

Yoga for Chronic Disease Management

Does Yoga Improve Recovery and Shorten Wound Healing Time?

References:

Cruikshank, Tiffany. Optimal Health for a Vibrant Life: A 30-Day Program to Detoxify and Replenish Body and Mind. Createspace Independent Pub, 2014.

Gargouri, Manel, et al. “Spirulina or dandelion-enriched diet of mothers alleviates lead-induced damages in brain and cerebellum of newborn rats.” Food and chemical toxicology 50.7 (2012): 2303-2310.

Schütz, Katrin, Reinhold Carle, and Andreas Schieber. “Taraxacum—a review on its phytochemical and pharmacological profile.” Journal of Ethnopharmacology 107.3 (2006): 313-323.

You, Yanghee, et al. “In vitro and in vivo hepatoprotective effects of the aqueous extract from Taraxacum officinale (dandelion) root against alcohol-induced oxidative stress.” Food and chemical toxicology 48.6 (2010): 1632-1637.

Let’s Talk Yoga Medicine with Valerie Knopik

More and more, the worlds of science and natural remedies and practices continue to work in tandem with one another. Athleisure Magazine took some time to chat with Valerie Knopik who works with Tiffany Cruikshank, the founder of Yoga Medicine that blends these principles together.

Let’s Talk Yoga Medicine

Tell us about your background and how you came to work with Yoga Medicine.

I have a PhD in Psychology and I am currently an academic researcher/scientist mentoring postdoctoral fellows and junior faculty at Brown University. I will be moving into an endowed professorship in the Department of Human Development and Family Studies at Purdue University this summer. In addition to this career in science, I also teach yoga and have been a student in advanced training with Yoga Medicine since 2014.  In late 2016 at a module in Sedona, Tiffany Cruikshank (founder of Yoga Medicine) and I started talking about the possibility of a research project and that was the exciting beginning of the Yoga Medicine Research Institute and my role as the Director of Research for Yoga Medicine.

What is Yoga Medicine and why is this a way to blend science and nature together?

Yoga Medicine is a thorough, anatomically-based training system that trains teachers across the globe to work more powerfully with their students. Yoga Medicine teachers are trained in the fusion of East and West to blend the best of anatomy and physiology with the traditional practice of yoga, including pranayama, mindfulness and meditation. It is this foundation that makes Yoga Medicine the perfect venue for building a research program that focused on the combined application of yoga, meditation, and mindfulness to improve health and the human condition.

Our vision is to educate and empower our global communities to use yoga therapeutically based on a deeper understanding through purposeful and well-designed research. Through this effort, I have the honor of mentoring and training our Yoga Medicine community of teachers in the nuances of conducting research and to deliver purpose-driven yoga, meditation and mindfulness instruction as a way to robustly examine its effects on various health outcomes.  In my view, this continues the push, already started by Yoga Medicine, to raise the bar on what it means to be yoga teacher.  Education.  Experience.  Results.

How can one access Yoga Medicine?

To learn about all things Yoga Medicine, you can start by visiting the website. On this site, you can find information about our mission, the Research Institute, the Seva (or service) arm of Yoga Medicine, training, articles written by our teachers and contributors and so much more.  Our Find a Teacher platform is also available via the website or directly. This is a free service that Yoga Medicine provides to connect you directly with a Yoga Medicine trained teacher in your area. Through this service, you can find all teachers in your area and you can see what trainings they have completed with Yoga Medicine so that you can find a teacher that meets your needs.

With Spring being upon us, what is a detox that one can do to get their summer body prepped?

A detox is a process where one abstains from or rids the body of toxic or unhealthy substances.  Spring is synonymous with the idea of spring cleaning and that doesn’t have to mean strictly of the house or closet variety of spring cleaning.  There are simple ways to participate in a detox or cleanse (for more details, check out Tiffany Cruikshank’s book:  Optimal Health for a Vibrant Life).  Here are some simple strategies that you can do to get a jump start. If you can stay on this detox for about three weeks (the amount of time they say it takes to break a habit), you will notice some significant changes in how you look and feel!

Suggestions:

  • Eliminate coffee and alcohol. If possible, eliminate all caffeine. If you must keep a small amount of caffeine in your routine, consider substituting green tea for coffee – the caffeine in tea is gentler on your system
  • Eliminate added sugar – become an avid label reader – sugar hides everywhere
  • Eat fresh and organic vegetables and foods
  • Start your day with a large glass of water with the juice of one half of a lemon.  Drink a lot of water throughout the day.
  • Drink herbal, decaffeinated tea – not only will this increase your fluid intake and hydration, but the antioxidants in tea are beneficial as well
  • Be aware of allergens and pollutants in your environment and add skin brushing and the neti pot to your daily routine.
  • Consider eliminating dairy and wheat for the three-week period
  • If you eat meat, try eating only local, free-range, organic, and grass-fed offerings. Find a local farm so that you are aware of where you are getting your meats from. Bonus: you are supporting local businesses!
  • If you eat fish, try to find wild caught offerings
  • Move your body!  Yoga, exercise, whatever it is will increase circulation to all systems to help move toxins out
  • Sweat – through exercise or the sauna – regularly!

For those that have kicked into their workout methods of choice, how can we keep our bodies injury-free and what can we do when we have strained muscles in our arms, butts, and legs when we start a new workout routine?

To keep your body injury-free, it is important to make the time to restore the muscles that you challenge during your workout of choice. This can be something as simple as taking the time to stretch before and after physical activity. Other ways to make sure you restore your system include myofascial release, massage, mindfulness, water intake, sleep, and nutrition. A muscle strain implies damage to the muscle and can be a result of fatigue, overuse, or improper use. The most important strategy for muscle strain is a period of rest, followed by light stretching or myofascial release to encourage circulation to the area.

Stress tends to creep in from time to time – what are three things that we can do in terms of breathing techniques and movements to manage it?

Here are three techniques:

  1. Basic Breath Awareness:

    Lay on your back with your knees bent, feet flat on the floor and at least hip-distance apart.  Once comfortable, place a hand on your abdomen. Begin to just notice your breath. Does your breath feel strained or smooth? Just observe your breath without judging whether or not you’re doing it right or wrong. Gradually begin to make your breath as relaxed as possible. Introduce a slight pause after each inhale and after each exhale. Now begin to bring your awareness to your hand on your abdomen. Notice that with each inhale, your abdomen rises, and with each exhale, your abdomen contracts. Without being forceful, just begin to gently try to expand the abdomen on the inhale and contract the abdomen on the exhale to support the natural movement of your diaphragm. Continue for 6-12 breaths.

  2. Long Exhale:

    The long exhale is a 1:2 breathing practice that involves gradually increasing the length of your exhale until it is twice the length of your inhale.  Start with basic breath awareness as outlined above.  With a hand on your abdomen, mentally count the length of both your inhale and your exhale for several breaths. Start to gradually make the inhale and exhale the same length. Once your inhale and exhale are of equal length, then gradually increase the length of your exhale until it is up to twice the length of your inhale.  If you start to feel stressed, back off to a ratio that is more comfortable for you. It’s important to note that an exhale that is even slightly longer than your inhale can have profound relaxing effects on the nervous system. Continue for 6-12 breaths.

  3. Chandra Bheda – Lunar/Moon Breath:

    In this breath practice, you inhale only through the left nostril and exhale only through the right nostril. In Eastern traditions, the left side of the body represents the moon, or more yin and calming energy, while the right side of the body represents the sun, or more yang fiery energy. Therefore, in Chandra Bheda, we encourage the lunar, calming energy to enter the body, and we encourage the fiery yang energy to decrease – which will help bring the body back into balance.

    To try this breath: Sit in a comfortable position. Allow your left hand to rest in your lap. Look at your right hand. Fold the index finger and middle finger into the palm. For this breath practice, you will only use the right thumb and the right ring finger. With your thumb on your right hand, close off the right nostril and inhale through the left side of the nose. Then use the ring finger to close off the left nostril, release the thumb and exhale through the right nostril.  Start with an inhale and exhale that are about a count of 5-10 and are equal in length. Repeat for 3-9 rounds.

What are 3 stretches that we can do when a short travel experience becomes a longer one due to flight delays, missed connections etc?

One of the most important things you can do is to make sure you move around during these delays.  We have a tendency to just sit and wait, but adding some gentle movement can have significant effects on mood, anxiety, and just the feeling of tension that accumulates in the body.  Even just a walk around the terminal can help.  Here are a few specific stretches that you can do to ease travel tension and anxiety:

  1. Neck Release

    Sit in a comfortable position with a tall spine. Allow the right ear to drop down toward the top of the right shoulder. Keeping the head in this position, try to send the top of the left shoulder away from the left ear so that you create a lot of space on the left side of the neck.  From here, think of your chin like the rudder of a boat and gently shift the chin toward the right shoulder (keep sending the left shoulder away from the left ear as you do this). Move the chin slowly to find additional areas of neck tension. Stay for 5-10 breaths. To bring your head back to neutral, place the right palm on the right cheek and gently assist the head back to center.  Repeat on the left side.

  2. Standing (Or Seated) Side Stretch

    Reach the arms high toward the ceiling. If possible, clasp the hands overhead. Imagine that you can lift and lengthen the torso out of the pelvis. Find this by reaching up towards the ceiling, then side bend to the right.  Think about wrapping the right armpit toward the wall that you are facing so that you are less likely to collapse in the chest. Stay for 2-4 breaths. On an inhale and come back to center. Then, side bend to the left.

  3. Legs Up the Wall

    Find a deserted or less busy part of the airport with a bit of wall space. Lay down on your back and send your legs up the wall. Try to scoot your sitting bones as close the wall as possible. Allow the back of the skull and the entire spine to rest on the floor. Allow the legs to rest on the wall. Find a comfortable position for your arms. Stay anywhere from 5-30 minutes.

  4. Forward Fold (Seated in a Chair, Standing, or on the Floor)

    Getting the head below the heart can be an excellent and accessible way to reduce anxiety. It can also stretch the lower back muscles that tend to get tight when we sit for too long.

Do you think that more doctors and practitioners are realizing that it is essential for new and old medicines to come together? Where do you see that in the next few years?

I do believe that there is a movement toward a more collaborative and blended approach to health and self-care. For example, I work with a client who has been experiencing chronic low back pain. With his permission, I have worked alongside his acupuncturist and chiropractor to develop a plan for him. I think that both doctors and practitioners are open to this blended approach. Unfortunately, at this point, I believe it is still primarily on the shoulders of the practitioners/patients/clients. Currently, doctors are not yet seeking out ways to bring together Eastern and Western medicine.

However, there are more and more initiatives for bringing mindfulness into the traditional Western medical settings, such as hospitals and doctor’s offices. These efforts lead me to believe that, in the near future, we will see more of the traditional Eastern modalities of Chinese Medicine, acupuncture, pranayama, and mindfulness being more formally incorporated into approaches to health care and self-care. Also, with information and education comes the possibility for more comprehensive approaches to health.

Medications & Yoga

Margeaux Amerine, Pharmacist and  RYT-200 graduate shares a list of some common medications that can have significance as they relate to a yoga practice.

Medications & Yoga

Medication use is a part of our client intake form, thus having general knowledge of their medications in relation to yoga is important for understanding their overall health, level of pain, as well as how these medications might affect their yoga practice.

Topics:

  • Bone and Joint Disorders
  • Cardiovascular
  • Endocrine
  • Neurologic
  • Psychiatric
  • Respiratory

Bone and Joint Disorders

Common disorders include osteoarthritis, osteoporosis, rheumatoid arthritis and gout.

1. Osteoarthritis (OA)

A common, slowly progressive disorder affecting primarily the weight bearing joints of the peripheral and axial skeleton. It is characterized by progressive deterioration and loss of articular cartilage resulting in osteophyte formation, pain, limitation of motion, deformity, and progressive disability. Inflammation may or may not be present in the affected joint.

Pharmacological Treatment: Pain relief (see neurologic section for complete list of pain relievers and their implications in relation to yoga.)

Considerations: (see neurologic section for complete list of pain relievers and their implications in relation to yoga.)

2. Osteoporosis

Characterized by low bone mass and deterioration of bone tissue leading to bone fragility and increased fracture risk.

Pharmacological Treatment:

  • Calcium
  • Vitamin D
  • Bisphosphonates: Alendronate (Fosamax) Risedronate (Actonel), Ibandronate (Boniva)
    • Bisphosphonates bind to hydroxyapatite in bone and decrease resorption by inhibiting osteoclast adherence to bone surfaces.
  • Others include but less common: Selective Estrogen Receptor Modulators (SERMs), calcitonin, estrogen and hormonal therapy, phytoestrogens, testosterone and anabolic steroids, bone formation therapy

Considerations: For patients with osteoporosis who are at risk for fractures, the aims are to prevent falls, fractures, and their complications. Developing a yoga prescription with awareness that these individuals are at increased risk for a fracture is important, however strength exercises may help prevent bone loss and decrease falls and fractures.

3. Rheumatoid Arthritis (RA)

A chronic and usually progressive inflammatory disorder of unknown etiology characterized by involving several joints, with symmetric joint involvement and systemic manifestations.

Pharmacological Treatments:

  • Disease-Modifying Antirheumatic Drug (DMARD): methotrexate, hydroxycholorquine, sulfasalazine, and leflunomide
  • Non-Steroidal Anti-Inflammatories: (see neurologic section for complete list)
  • Biologic Agents: Enbrel, Remicade, Humira
  • Corticosteroids: prednisone, methylprednisolone
    • Corticosteroids can cause severe, adverse reactions including tendon rupture and has common side effects including muscle weakness and dizziness/vertigo.

Considerations: Joint swelling, stiffness, and pain are common with RA patients. Long-term corticosteroid treatment will increase the risk for tendon rupture.

Cardiovascular Disorders: (not limited to)

Arrhythmia

Defined as loss of cardiac rhythm, especially irregularity of heartbeat.

Pharmacologic Treatment: Quinidine, Procainamide, Disopyramide, Lidocaine, Mexiletine, Tocainide, Flecainide, Propafenone, Beta-Blockers, Amiodarone, Bretylium, Dofetilide, Sotalol, Ibutilide, Verapamil, Diltiazem

Heart Failure (HF)

A clinical syndrome caused by the inability of the heart to pump sufficient blood to meet the metabolic needs of the body.

Pharmacologic Treatment:

  • ACE Inhibitors: Captopril, Enalapril, Lisinopril, Quinipril, Ramipril, Fosinopril, Trandolopril
  • Beta-Blockers: Carvedilol, Metoprolol, Bisoprolol
  • Diuretics: Hydrochlorothiazide, Metolazone, Furosemide, Bumetanide, Torsemide
  • Digoxin
  • Others: Spironolactone, ARBs (losartan, candesartan, valsartan), Nitrates, Hydralazine, Amiodarone

Hyperlipidemia

An elevation of one or more of the following: cholesterol, cholesterol esters, phospholipids, or triglycerides.

Pharmacologic Treatment:

  • Bile Acid Resins: Cholestyramine, Colestipol, Colesevelam
  • Niacin
  • HMG-COA Reductase Inhibitors (STATINS): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin, Simvastatin
    • Can cause generalized muscles aches (myalgia/myopathy) as well as the rare, but serious condition of rhabdomyolysis. Many patients experience muscle aches daily while taking these medications.
  • Fibric Acids: Gemfibrazole, Fenofibrate
  • Others: Zetia, Fish Oil Supplements

Hypertension

Persistent elevation of arterial blood pressure.

Pharmacologic Treatment:

  • Diuretics: Chlorthalidone, Hydrochlorothiazide, Metolazone, Bumetanide, Furosemide, Torsemide, Amiloride, Triamterene, Spironolactone
  • Beta-Blockers: Atenolol, Betaxolol, Bisoprolol, Metoprolol, Nadolol, Propranolol, Carvedilol, Labetolol
  • ACE Inhibitors (angiotensin-converting enzyme inhibitors): Benazapril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril
  • ARBs (angiotensin II receptor blockers): Candesartan, Irbesartan, Losartan, Omesartan, Telmisartan, Valsartan
  • Calcium Channel Blockers: Amlodipine, Felodipine, Nifedipine, Diltiazem, Verapamil
  • Others: Alpha-Blockers, central alpha2-agonists, adrenergic inhibitors, and vasodilators

Anticoagulation

blood-thinners (anti-coagulants and antiplatelets) These medications are often used in but not limited to, cardiac patients to prevent clot formation when indicated by a specific condition.

Pharmacologic Treatment:

  • Apixaban (Eliquis)
  • Dabigatran (Pradaxa)
  • Edoxaban (Savaysa)
  • Rivaroxaban (Xarelto)
  • Warfarin (Coumadin)

Considerations: Can increase a patient’s risk for bleeding and bruising. Special care should be taken in a client on Warfarin as the blood thinning effects can cause major or fatal bleeding. Reducing the risk of falls and excessive bruising should be considered when creating a yoga prescription or general yoga practice.

General Considerations for Cardiovascular Disorders:

These patients without exception need to be cleared from a medical professional before beginning any exercise regimen. Regular aerobic exercise has been shown to improve outcomes in patients with hypertension and hyperlipidemia. These disease states come with various, but not limited to, symptoms including, shortness of breath, fatigue, dizziness, palpitations, chest pain, syncope, confusion, cough, and exercise intolerance. Most medications listed to treat these conditions also come with the same adverse side effects that are similar to the symptoms they are treating. Again, it cannot be stressed enough that these patients must be cleared for physical activity before beginning yoga.

Endocrine Disorders:

Diabetes Mellitus (DM)

Group of metabolic disorders characterized by hyperglycemia and abnormalities in carbohydrate, fat, and protein metabolism. It results from defects in insulin secretion, insulin sensitivity, or both. Chronic microvascular, macrovascular, and neuropathic complications may ensue.

Pharmacologic Treatment:

  • Insulin: Humalog, Novolog, Apidra, Humulin R, Novolin R, Humulin N, Novolin N, Lanuts, Levemir
  • GLP-1 Receptor Agonists: Tanzium, Trulicity, Byetta, Bydureon, Victoza
  • Amylin Analogue: Symlin
  • Sulfonylureas: Glipizide, Glyburide, Glimiperide
  • Biguanide: Metformin
  • Meglitinides: Prandin, Starlix
  • Thiazolidinediones: Pioglitazone, Rosiglitazone
  • DPP-4 Inhibitors: Januvia, Onglyza, Tradjenta, Nesina
  • SGLT2 Inhibitors: Invokana, Fargixa
  • Alpha-glucoside Inhibitors: Acarbose, Miglitol
  • Bile Acid Sequestrants: Welchol

Considerations: Low blood sugar or hypoglycemia is the primary side effect with most of these treatment options. Low blood sugar can lead to fatigue, dizziness, fainting. Most patients benefit from increased physical activity. Aerobic exercise can improve insulin resistance and glycemic control and may reduce cardiovascular risk factors, contribute to weight loss or maintenance, and improve wellbeing. Exercise should be started slowly in previously sedentary patients. Older patients and those with cardiovascular conditions should receive approval from medical professional before beginning exercise.

Neurologic Disorders:

Pain

an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

  • Types:
    • Nociceptive (acute) pain is either somatic (arising from skin, bone, joint, muscle, or connective tissue) or visceral (arising from internal organs such as the large intestine or pancreas).
    • Neuropathic (chronic) pain is sustained by abnormal processing of sensory input by the peripheral or central nervous system. There are a large number of neuropathic pain syndromes that are often difficult to treat (e.g. low back pain, diabetic neuropathy, post herpetic neuralgia, cancer-related pain, spinal cord injury).

Pharmacologic Treatment:

Opioid Pain Medication

Often used to treat chronic, severe pain. These medications bind to various opioid receptors, producing analgesia (pain-relief) and sedation. In general, these medications can cause sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression.

Considerations: The effects of the opioid analgesics are relatively selective, at normal therapeutic concentrations, these agents do not affect other sensory modalities, such as sensitivity to touch, sight, or hearing, however, as the dose increases, so do the undesirable side effects. Patients in severe pain may receive very high doses of opioids with no unwanted side effects, but as the pain subsides, they may not tolerate even very low doses.

Frequently, when opioids are administered, pain is not eliminated, but its unpleasantness is decreased. Special care should be taken with these as pain perception may be modified. In treatment of acute pain or injury, exercise should be stopped completely. Yoga should only be started after approval from a medical profession. In treatment of chronic pain and long-term opioid use, extreme caution should be used with these clients. Collaboration with the primary care physical, specialist, or physical therapist is important with these individuals.

  • Codeine
  • Codeine/Acetaminophen (Tylenol #3, Tylenol #4)
  • Fentanyl (Duragesic, Actiq) -most common form in out-patient use: patch
  • Hydrocodone (Zohydro ER)
  • Hydrocodone/Acetaminophen (Vicodin, Lortab, Lorcet, Norco)
  • Hydromorphone (Dilaudid)
  • Meperidine (Demorol)
  • Methadone (Dolophine, Methadose)
  • Morphine (Avinza, Kadian, MS Contin) – Immediate and Extended-Release
  • Oxycodone (OxyContin, Roxicodone) – Immediate and Extended-Release
  • Oxycodone/Acetaminophen (Percocet, Endocet, Roxicet)

Tramadol (Ultram)

 Non-opioid pain reliever, often used to treat acute or chronic moderate pain. Produces an analgesic effect by binding to mu opioid receptors and weakly inhibits norepinephrine/serotonin reuptake.

Consideration: Although this medication is a non-opioid pain reliever, pain perception may be modified.

Acetaminophen* (Tylenol)

Non-opioid pain reliever often used to treat acute mild to moderate pain. Produces an analgesic effect by weakly inhibiting COX-1 and COX-2 (cyclooxygenase) receptors. *These medication is available over-the-counter or OTC, meaning without a prescription.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Often used to treat acute and chronic mild to moderate pain with inflammation. The medications inhibit cyclooxygenase; reduce prostaglandin, and thromboxane synthesis.

Considerations: There can be increased risk for bleeding when taking these medications. These medications play an important role in acute injury by helping to decrease the ‘inflammation cycle’ by, with the exceptions of acetaminophen, preventing formation of prostaglandins produced in the response to noxious stimuli, thereby decreasing the number of pain impulses receive by the CNS. In terms of acute injury or pain, yoga should be stopped or limited and only after approval from a medical profession. You will also see chronic use of these medications for their anti-inflammatory pain relieving properties, but also come with the increase risk for developing a GI (gastrointestinal) bleed. All NSAIDs have some analgesic effects, but there is high interpatient variability in therapeutic response to NSAIDs.

  • Aspirin* (Bayer, Bufferin, Ecotrin, Exedrin)
  • Celecoxib (Celebrex)
  • Diclofenac potassium (Cataflam)
  • Diclofenac sodium (Voltaren, Voltaren XR)
  • Diclofenac sodium with misoprostal (Arthrotec)
  • Diflunisal (Dolobid)
  • Etodolac (Lodine, Lodine XL)
  • Flurbiprofen (Ansaid)
  • Ibuprofen (Advil, Motrin, Motrin IB)
  • Indomethacin (Indocin, Indocin SR)
  • Ketoprofen
  • Ketorolac (Toradol) – used to treat acute, severe pain only
  • Magnesium salicylate* (Bayer Select, Doan’s Pills)
  • Meloxicam (Mobic)
  • Nabumetone (Relafen)
  • Naproxen (Naprosyn)
  • Naproxen Sodium* (Aleve)
  • Oxaprozin (Daypro)
  • Piroxicam (Feldine)
  • Sodium Salicylate (various generics)
  • Sulindac (Clinoril)

Chronic neuropathy (nerve pain)

These medications work by activating or blocking various neurotransmitters and receptors on the brain. Historically, many of these medications were indicated for other uses, but with time have been given secondary indications for the treatment of neuropathy.

Considerations: These medications, specifically, do not work on the same receptors as opioids. The patient will feel decreased pain, however pain perception is not modified.

  • Amitriptyline (Elavil) – Depression, migraine
  • Duloxetine (Cymbalta) – Depression/anxiety, fibromyalgia, and chronic muscle or bone pain
  • Gabapentin (Neurontin) – Seizures
  • Nortriptyline (Pamelor) – Depression
  • Pregabalin (Lyrica) – Fibromyalgia, seizures

Muscle relaxants

Often used to treat acute or chronic muscle spasms. Exact mechanism of action is unknown for many of these medications; all are centrally-acting muscle relaxants; some work on neurotransmitters in the brain resulting in sedation and alteration in pain perception, reduced spasticity, depression of central nervous system activity, as well as inhibiting monosynaptic and polysynaptic spinal reflexes.

Considerations: These medications are often used in treatment of acute injury or pain; hence all physical activity should be stopped. Chronic use of muscle relaxants is not common as acute use, and is typically seen, but not limited to, patients who have neurologic disorders such as multiple sclerosis and chronic pain due to injury; in these client’s collaboration with a primary care physician, specialist, or physical therapist is key.

  • Baclofen
  • Chlorzoxazone (Lorzone, Parafon Forte)
  • Carisoprodol (Soma)
  • Cyclobenzaprine (Flexeril, Amrix)
  • Diazepam (Valium)
  • Metaxalone (Skelaxin)
  • Methocarbamol (Robaxin)
  • Tizanidine (Zanaflex)

Topical Pain Relievers

Often used in acute or chronic mild to moderate pain. These medications are applied topically to the area of pain.

  • OTC: products containing menthol, camphor, salicylates, capsaicin. (Icy-Hot, Biofreeze, Bengay, Blue-Emu, Capzasin etc…) – these should really only be for acute, short-term use.
  • Lidocaine: these products contain lidocaine, which is a numbing agent.
  • Lidoderm Patches: prescription only – Ointment, gels, cream: some are OTC others are prescription depending on strength.
  • Diclofenac Gel (Voltaren) – Anti-inflammatory gel applied directly to painful joint. May be preferred method of chronic NSAID therapy as it decreases risk for GI bleed.
  • Diclofenac Patch (Flector) – Anti-inflammatory patch applied directly to painful area.

General considerations for Neuropathic Disorders:

This information is not here for you to diagnose your client’s level of pain, but to rather understand their general pain level, duration of pain treatment, and to provide insight into their general health. In my practice, I see patients on acute and chronic pain medications everyday. In general, many patients on chronic pain medication are able to perform daily functions while taking these medications. This does not go without saying that any type of opioid intake can cause pain perception modification, respiratory depression and death in not only acute but also chronic use and any person under the care of a physician should be cleared for physical activity. Most importantly this information can provide you more insight into understanding pain in our clients. Pain itself is perceptive; one person’s level 10 pain might be another person’s level Listening and being aware are the best tools you can use.

Psychiatric Disorders

 Anxiety disorders

A constellation of disorders in which anxiety and associated symptoms are irrational or experienced at a level of severity that impair functioning.

Pharmacologic Treatment:

  • Benzodiazepines: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Temezapam (Restoril), Triazolam (Halcion)

Considerations: Can increase risk for falls (especially in the elderly), dizziness, fatigue, impaired coordination, and drowsiness. Due to their sedative effects, extreme caution should be used if a patient is taking one of these medications while doing yoga. Treatment with these medications can be acute, or during a period of heightened anxiety or panic, as many of them have a short duration of action, or can be used chronically as daily therapy to treat some psychiatric disorders, seizure disorders or as a muscle relaxant. Having knowledge of your clients intake and frequency can help determine the appropriateness and safety related concerns in associated with a yoga practice. Collaboration with a client’s primary care physician, counselor or therapist can help to determine appropriateness and safety related concerns.

  • Antidepressants: escitalpram, imipramine, paroxetine, venlafaxine
  • Azapirones: buspirone
  • Diphenylmethane: hydroxyzine

Major Depressive Disorder

Characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes.

Pharmacologic Treatment:

  • Selective Seratonin Reuptake Inhibitors (SSRI): Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
  • Serotonin/Norepinephrine Reuptake Inhibitors: Venlafaxine, Duloxetine, Desvenlafaxine (Pristiq), Levomilnacipran (Fetzima)
  • Aminoketones: Buproprion
  • Triazolopyridine: Nefazodone, Trazodone
  • Tricyclic Antidepressants: amitriptyline, Clomiprimine, Doxepin, Imiprimine, Despiramine, Nortripyline,
  • Monoamine Oxidase Inhibitors: Phenelzine, Tranylcypomine
  • 5-HT1A Receptor Antagonist: Vilazodone (Viibryd)
  • 5-HT3 Receptor Antagonist: Vortioxetine (Brintellix)
  • Noradrenergic Antagonists: Mirtazipine

Considerations: Most medications to treat these condition come with corresponding side effects to include, but not limited to, dizziness, fatigue, headache, impaired coordination, drowsiness, anxiety, sedation, insomnia, orthostatic hypotension; this should be taken into consideration when designing a yoga practice. Counseling, stress management, cognitive therapy, meditation, supportive therapy, and exercise can be powerful tools and should be used collaboration with other care providers such as counselors, therapists, or medical professional; this includes the treatment of other psychiatric disorders such as Alzheimer’s and Schizophrenia.

Respiratory Disorders: (not limited to)

Asthma

A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. Episodes of wheezing, breathlessness, chest tightness, and coughing.

Chronic Obstructive Pulmonary Disease

Progressive airflow limitation that is not fully reversible. Airflow limitation is usually both progressive and associate with an abnormal inflammatory response of the lugs to noxious particles or gasses. The most common conditions comprising COPD are chronic bronchitis and emphysema.

Pharmacologic Treatment:

  • Inhaled Beta-agonists: Albuterol, Formoterol, Salmeterol, Levalbuterol
  • Anticholinergics: Ipratropium, Tiotropium
  • Oral Corticosteroids: Prednisone, Methylprednisolone, Prednisone
    • Corticosteroids can cause severe, adverse reactions including tendon rupture and has common side effects including muscle weakness and dizziness/vertigo.
  • Inhaled Corticosteroids: Beclomethasone, Budesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
  • Others: Theophyline, Cromolyn, Accolate, Montelukast

Considerations: A medical professional should clear clients with these conditions before beginning an exercise regimen. In contrast to oral corticosteroid therapy where unwanted side effects like tendon rupture, muscle weakness and dizziness are a concern, inhaled corticosteroids have less systemic absorption. Beta-agonists can have unwanted side effects to include wheezing, chest tightness, trouble breathing, nervousness, tremor, chest pain, palpitations, nausea, or dizziness. Due to the nature of these conditions and associated side effects, collaboration with a medical professional is important for the safety of the individual.

General considerations on Respiratory Disorders:

This information is not meant for you to diagnose or plan treatment for your client, but to better understand and aid you and your client in developing a safe yoga practice. It cannot be stressed enough that these common medical conditions, but not limited to, come with increased risk when patients partake in physical activity, thus making sure they care cleared by their physician for physical activity and collaboration with their care providers is crucial for their safety, as well as your own.

This information is not all-inclusive and if you have any questions regarding medications related to yoga, please feel free to email me at mcschoofs@gmail.com.

Sources:

Wells, Barbara G., Joseph T. DiPiro, Terry L. Schwinghammer, and Cindy W. Hamilton. Pharmacotherapy Handbook. Sixth ed. New York: McGraw-Hill Medical Pub. Division, 2006. Print.

Bridging Yoga Medicine & Western Medicine: Part IV

Part 4: Healthcare Providers as Clients

This is the fourth installment in a series of articles for yoga teachers on ideas for networking and sharing yoga practice with the healthcare community in your locale.

  • In Part 1, we explored defining the types of patients you can best help and using Evidence-Based Medicine (EBM) to validate the ways in which you can support them.
  • In Part 2, we looked at ways to align your services within today’s healthcare world of patient-centered care and quality improvement.
  • Part 3 discussed awareness of self in relationship with yoga teacher colleagues and how being an industry expert can serve you and future clients. In this segment, we will investigate another potential way of approaching networking with medicine – recognizing healthcare providers as an additional community that can benefit from healing.

Doctor Heal Thyself

Chances are when you meet with the medical director of a healthcare facility and/or healthcare providers in a clinic you hope to get involved with, like many other people out there, they may not know much about yoga’s potential beyond group exercise. A large part of your time will be spent educating them. Perhaps you will use talking points you put together after reflecting upon earlier articles in this series.

Meet healthcare professionals where they are at. By using language familiar to them, you will be able to draw their cognitive interest with ease. Another crucial part of outreach to consider is experiential – simultaneously drawing them in physically, emotionally, and maybe (dare I even say it?) spiritually.

There could not be a more suitable time to reach out in this way to physicians. In the United States, the healthcare workforce is experiencing work-related stress and burnout in, what even the US Surgeon General considers, alarming proportions.

Stress and Burnout in Medicine

Defining Burnout

Characterized by: (1) emotional exhaustion, or a loss of enthusiasm for work; along with (2) feelings of cynicism or depersonalization; and (3) a decreased sense of personal accomplishment at work. Physicians and other members of the healthcare team, including medical trainees, often experience burnout as a result of continued job-related stress.

In the United States, more than half of physicians may be experiencing professional burnout. A 2014 Mayo Clinic study in partnership with the American Medical Association revealed 54% of surveyed physicians reported at least one key indicator of burnout. This is an increase from 46% in 20111. Although burnout affects physicians in all specialties of medicine, those on the front lines of care including emergency medicine, internal medicine, and family medicine, are at greater risk. 2

Burnout amongst physicians during residency, an inherently stressful period of medical training, is perhaps even more prevalent. Surveys among residency programs from various specialties across the US report burnout to affect up to 60% of trainees.3

Physicians are not alone in their experiences. Amongst nurses, 34% of hospital nurses and 37% of nursing home nurses report burnout, while 22% working in other settings are affected as well.4

The Consequences

The consequences of burnout in the healthcare workforce are multi-dimensional. Personally, the increased distress can contribute to stress-related health concerns and unhealthy coping behaviors, such as substance abuse.3 Depressive symptoms, as well as professional burnout, are strongly correlated with suicidal ideation amongst doctors.3,5

The culture of medicine can begin to take a toll as enthusiasm in work decreases and cynicism increases, affecting professionalism and healthcare team morale. The impacts of burnout can even drive some practitioners to leave their careers altogether.3

Implications for patient care are also present as burnout has been associated with suboptimal quality of care and medical errors.3 Distress has also been reported to create poorer relationships with patients, as emotional exhaustion and depersonalization are inversely correlated with the ability to provide empathy.3,6

Risk Factors

Though it is a blend of external and internal factors that contribute to the perfect storm where burnout in medicine can arise, studies suggest institutional characteristics are significant determinants of burnout.3

Professional and environmental characteristics like workload, Electronic Health Record (EHR) tasks, work-hours, patient volumes, relationships with colleagues, autonomy, and dissatisfaction with supervisors and organizational leadership are all contributors.3,7 When work hours are decreased, a phenomenon called “work compression” takes over where physicians are expected to complete the same amount of administrative work while providing high-quality compassionate patient care in a shortened period of time.1,3 Personally, conflicts in relationships, work/life balance, illness, and financial debt from educational loans are additional stressors leading to burnout.3

Today’s physicians find their souls in battle, caught between the demands of growing healthcare systems along with insurance companies, in conflict with their innate desire to truly connect with their patients in meaningful ways, building compassion and trust into the heart of the care they provide.

Protective Factors

Although many of the institutional factors described above are beyond individual control, there are personal behaviors that have been shown to be protective against burnout. These include: (1) seeking and giving social support (2) engagement in activities that help to create meaning both at work and at home; and (3) health-promoting behaviors, particularly sleep hygiene and stress management.3,8

In a study I helped to conduct at the University of Buffalo in Buffalo, NY, resident physicians who reported no regular engagement in personal emotional and/or spiritual practices to support wellbeing were two times more likely to be emotionally exhausted when compared to residents who reported engagement.   Similarly, those who reported no physical activity were almost three times more likely to be emotionally exhausted when compared to medical residents who reported 150+ minutes of at least moderate intensity physical activity per week.9

Solutions: A Role for Mindfulness and Yoga in Healthcare Provider Self-Care

The wide range of factors impacting healthcare worker burnout warrants solutions that effect change at multiple levels – from broader systemic, institutional layers through professional and personal dimensions. A recent meta-analysis reveals that both individual-based and organizational strategies can lead to equally meaningful reductions in healthcare provider burnout.10

While administrators work on vital structural changes, interventions to nurture personal wellness can further support provider health and resilience. Of particular interest to yoga professionals is the role mindfulness programs have been playing to increase physicians’ awareness of burnout in its early stages and temper its effects. By encouraging engagement in self-care activities and creating meaning in the workplace, mindfulness-based programs can provide an evidence-based means for healing healthcare provider burnout.8,10

Mindfulness trainings for healthcare professionals can include meditation and yoga to develop greater self-awareness, cognitive behavioral strategies to lower reactivity in stressful situations, mindful communication to strengthen interpersonal relationships, reflection, and discussion. Participation in a twelve-month program utilizing these elements resulted in significant reductions of burnout and mood disturbances while increasing mindfulness and empathy amongst primary care physicians both in the short and long term.11

Abbreviated interventions have also been successful as evidenced by a 2013 study utilizing a weekend immersion on mindfulness followed by two evening sessions, web support, and a commitment by participants to engage in 10-20 minutes of mindful home practice. This pilot trial with primary care clinicians resulted in reductions in burnout, depression, anxiety, and stress sustained over nine months of follow-up.12 

How Can Yoga Professionals Get Involved?

With provider wellness finally getting some much-needed attention, the healthcare system is looking for ways to bring joy and meaning back into the practice of medicine. Given the potential for mindfulness practices to support resiliency in the healthcare workforce 7,8,10-13, now is a great time for yoga professionals to get involved. By serving this community, you could potentially help to heal burnout at a personal level while simultaneously exposing medical professionals to the healing potential of yoga, perhaps encouraging them to consider referring more patients to the practice as well.

Here are just a few starting ideas on how you may get involved:

  • Offer after-hours group classes and/or privates for healthcare professionals focused on self-care practices that enhance self-compassion and mindfulness.
  • Contact a clinic, hospital, or a local managed care organization about providing a workshop on mindful movement and meditation as a professional development activity for employees. Topics to include could be:
    • Brief history and philosophy of yoga, meditation, pranayama.
    • Overview of the physiological and psychological benefits of practices.
    • Restorative and Yin yoga – benefits and contraindications.
    • Meditation and mindfulness exercises for enhancing moment-to-moment awareness and identification of unhelpful thought patterns.
    • Using self-care practices to enhance gratitude, empathy, compassion, and resilience in the workplace and at home.
  • Partner with existing physician wellbeing programs or local physicians to integrate yoga into their offerings
  • Medical trainees can benefit from these programs. Consider contacting local medical, nursing, and physician assistant training programs as well as Graduate Medical Education (GME) departments to provide programs for students and faculty.

If you are a healthcare professional interested in learning more about evidence-based mindfulness programs tailored to physicians, please see the Mindful Practice website for further information. 

Potential Barriers

Please note the physician community can often be quick to site the laundry list of organizational and structural changes that contribute to burnout while resisting the potential for learning new personal practices. There are strong feelings amongst doctors about the need for resiliency training, and they are not entirely wrong. Doctors likely do have a strong reserve of coping skills that have helped them succeed thus far, but resilience is not just about bouncing back.

Resilience is about maintaining personal health AND being able to adapt, change, and grow. Self-care must be nurtured to help us flourish in this way. It is not one thing versus another, internal versus external characteristics; several factors contribute to physician wellness. Hence, it is advised to partner individual-based interventions with the organization level changes.13

I often remind physicians I have worked with that organizational changes, though very effective, can often take a long time to implement. While we keep advocating for the necessary shifts in healthcare, mindfulness and self-care practices are things we can do right now to impact personal wellness in this moment. If it can make us happier, and doesn’t have to take too much time, why not give it a chance?

Gratitude and A Request for Sharing

Thank you to Tiffany and Yoga Medicine for giving me the opportunity to share my thoughts and experiences with our community. I would love to hear more from all of you! What are strategies that have worked for you when reaching out to the medical community? Have you provided programs for healthcare professionals? What have been your experiences?

Please email me at rashmi.bismark@gmail.com to share your thoughts, comments, and questions. I plan to put together our Yoga Medicine Community’s tips into another follow-up article – so please contact me soon! Thanks again, and hope some pieces of this series have been helpful to you. Looking forward to hearing your ideas. Namaste.

References:

  1. Shanafelt T, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2016 Feb;91(2):276.
  2. Shanafelt T, et al. Burnout and Satisfaction With Work-Life Balance Among Physicians Relative to the General US Population. Arch Inten Med. 2012; 172(18):1377-1385.
  3. Dyrbye L and Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ.2016 Jan;50(1):132-49
  4. McHugh MD et al. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs. 2011;30(2):202-210.
  5. Andrew LB. Medscape: Physician Suicide. Oct 2016. http://emedicine.medscape.com/article/806779-overview#showall . Accessed Oct 26, 2016.
  6. Thomas MR, Dyrbye LN, et al. How do distress and wellbeing relate to medical student empathy? A multi-center study. J Gen Intern Med.2007 Feb;22(2):177-83.
  7. Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med.2014 Nov-Dec;12(6):573-6
  8. Epstein RM and Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013 Mar;88(3):301-3.
  9. Ahmad I, Bismark RS, Evans TB et al. Burnout and Health Promoting Behaviors Among Medical Residents in Buffalo, NY. American College of Graduate Medical Education Annual Conference, February 2013.
  10. West CP et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Sep 28. Epub ahead of print.
  11. Krasner MS, Epstein RM et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. 2009 Sep 23;302(12):1284-93.
  12. Fortney L, et al. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians. Ann Fam Med. 2013 Sep; 11(5): 412–420
  13. Epstein RM and Privitera MR. Doing something about physician burnout. Lancet. 2016 Sept 28. Epub ahead of print.

Bridging Yoga Medicine & Western Medicine: Part III

Part 3: Partnering from Within: Your Community Yoga Network

This is the third of a four-part series of articles for yoga teachers on networking within the medical community. In the first installment, we explored defining the types of patients you can best help and using Evidence-Based Medicine (EBM) to validate the ways in which you can support them. In the second, we looked at ways to align your services within today’s healthcare world of patient-centered care and quality improvement. Now we will delve into further alignment, this time exploring yourself in a relationship with your greatest asset – yoga colleagues teaching and working in your community.

Recognizing Strengths While Bringing Awareness to Ahamkara

In the eagerness to bridge yoga with the medical community in your locale, it is very important to carry mindful self-awareness with you. As yoga teachers within a broader network of skillful yoga providers, we must each recognize our unique strengths within the practice of yoga while creating familiarity with the strengths of those around us.

Though we may like to think we can help everyone, yoga teaches us to always be aware of our ahamkara (ego) and its sophisticated tendency to influence our actions.

Back in the summer between my undergraduate and medical school training, I interned with my university’s medical humanities department, working with a local massage therapist interested in building a network of complementary and alternative medicine (CAM) providers. At the time, the first integrative health clinics set our city abuzz. The concept was creative and unique for its time – a center for health promotion and self-care supported by complementary wellness providers poised to partner with individual medical providers.

Unfortunately, the clinic did not stay open for very long. Positioned as a stand-alone center, practitioners primarily referred patients to other practitioners within the clinic. Many CAM providers felt the center underutilized the city’s rich CAM community, which may have contributed to the center’s fate.

Ask yourself, what are your true drives for wanting to partner with neighboring medical providers?

For most all of us, the answer to this question is not simply to increase our number of clients. More likely, it is the drive within us to share the beauty of yoga and help others to heal which drives us to reach out to the healthcare world. With this commitment to service at the forefront, aligning yourself with peers in your community becomes a much more meaningful task.

Yoga Industry Expert

By networking with other yoga teachers and yoga therapists in your community, you can add value to the services you may potentially provide within healthcare. As you become an “industry expert” in your vicinity, you can position yourself to be a key liaison between the medical and yoga communities.

Taking on new client referrals from medical clinics can become as important as becoming the point person for referrals to others in the community. In this way, even if a medical clinic is not quite ready to take you on as an employee, they can be confident in your skills as a primary practitioner to refer patients to, whether it is for care or for triage to another skilled yoga teacher or therapist with different expertise.

Key Take-Aways from Parts 1-3:

  1. Define the community of patients you can best serve.
  2. Build support with the help of EBM to validate the ways in which you can help them.
  3. Understand how yoga can align with quality improvement trends in healthcare including patient-centered care, self-management, and cost-reduction.
  4. Nurture relationships with yoga teachers and therapists in your community as you become an industry expert, able to both teach and effectively bridge medical providers with the appropriate yoga care for their patients.

Join me for the next and final installment of this series where we will discuss one more approach to networking within healthcare – self-care for medical providers themselves. Healer, heal thyself.

Bridging Yoga Medicine & Western Medicine: Part II

Part 2: Positioning Yourself in Healthcare

This is the second of a four-part series of articles for yoga teachers on networking within the medical community. In the first installment we explored defining the types of patients you can best help and using Evidence-Based Medicine (EBM) to validate the ways in which you can support them. Although medically trained ears may find that information intriguing, they may not be able to picture how your services can fit in to their practice. Sometimes it can be helpful to explain how you and your yoga services can align with the overarching goals of today’s healthcare world.

HEALTHCARE TRENDS

Patient Centered Care

In addition to providing care that is safe, effective, timely, efficient, and equitable, in 2001, the Institute of Medicine (IOM) included patient-centered as one of the six aims of healthcare quality in the United States for the 21st Century. The IOM defined this key element of high-quality care as “care that is respectful of and responsive to individual patient preferences, needs, and values and [ensures] that patient values guide all clinical decisions 1.”

Since then, the concept of patient-centered care has taken a prime role as health care institutions, medical providers, community health planners, insurance companies, and hospital administrators have all made this quality indicator a priority. To this end, new models of medical care have been evolving, including the Patient-Centered Medical Home or Primary Care Medical Home (PCMH)2.

A PCMH provides a team-based, comprehensive and coordinated approach to meet the healthcare needs of each patient as a whole person.   The core team may include physicians, nurses, pharmacists, nutritionists, mental health professionals, and more who work together with patients and their families to optimize health.

It can be easy to see how yoga can align with these concepts of patient-centered, whole-person care. Bringing together physical activity with psychosocial well-being, yoga can provide a supportive care measure that fits into patient-centered ideals of comprehensive wellness and prevention. The US Veterans Affairs (VA) even features yoga as patient-centered whole health approach 3.

Additionally, as a Yoga Medicine-trained teacher, you have the knowledge and vocabulary to be an essential team player in the healthcare team. Dr. Stephen Dahmer MD, a family medicine physician in Manhattan, cites “soft style, anatomical knowledge, ability to spot red flags (and ability to effectively communicate this with medical providers) and overall compassion,” as key qualities one of his medical practices looked for when working with yoga teachers.

Self-Management

A large part of patient-centered care is also inviting patients take a more active role in their personal health care. Medical homes, clinics, community organizations, and even insurance companies have started to employ health coaches and/or provide group classes for patients on self-management and self-care. They teach patients how to manage their illnesses and make lifestyle changes to support their health. A classic example is the Dean Ornish Program for Reversing Health Disease, an intensive cardiac rehab class developed by Dr. Dean Ornish, MD, incorporating yoga, meditation, plant-based diet, exercise, and social support to alter patient risk profiles after heart attacks.

Yoga can be a creative add-on to existing self-care programs or may even be integrated in new, novel ways to support patients. Dr. Dahmer worked together with health coaches, who were also trained yoga teachers, at one of his offices to develop an innovative group program for his patients. “We started a class, called Body Lab, where I co-led with a yoga teacher – incorporating yoga, physical exam, anatomy, self-care – all in a group session, “ shares Dr. Dahmer.

Reducing Healthcare Costs

In addition to quality improvement, self-management, and patient-centered care, another broader goal of today’s healthcare is managing skyrocketing costs and reducing burden on the healthcare system as a whole. Fortunately, support is beginning to amount for mind body practices as potential ways to cut medical costs.

In October 2015, a retrospective study by researchers at Harvard showed that amongst a group of over 4000 patients who participated in Harvard mind body programs incorporating yoga and meditation, total healthcare utilization decreased by 43% one year after participation in the programs. In subgroup analyses, high utilizers of healthcare within the intervention group were 25% more likely to significantly reduce healthcare utilization when compared to high utilizers within the control group of over 13,000 patients from Boston-area health-care facilities 4.

Because studies like this one are observing broad statistical links, they cannot prove that mind body modalities were the sole contributor to reductions in healthcare demand. Regardless, this study offers hope and the possibility that safe and inexpensive interventions like yoga and meditation may help to control rising healthcare costs. That is music to any healthcare administrator’s ears, and another way to align your practice with broader healthcare ideals and trends.

Join me in my next installment of this series where we will explore further ways of positioning yourself as an ideal partner in wellness with the medical world.

References:

  1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
  2. US Department of Health and Human Services. Defining the PCMH. https://www.pcmh.ahrq.gov/page/defining-pcmh
  3. US Department of Veterans Affairs. VA Patient Centered Care: A Life-Changing Solution. http://www.va.gov/PATIENTCENTEREDCARE/features/A_Life_Changing_Solution.asp
  4. Stahl JE et al. Relaxation Response and Resiliency Training and Its effect on Healthcare Utilization. PLoS ONE 10(10): e0140212. Oct 2015.

Bridging Yoga Medicine & Western Medicine: Part I

YogaMedicine-trained practitioners are particularly well suited to partner and work efficiently with Western medical providers because they are a community of yoga teachers trained to understand the function and dysfunction of the human body. Most likely, as a Yoga Medicine teacher, you are already well connected to your local wellness and supportive health practitioners. Developing relationships with the medical community, however, can often be a bit more challenging.

I personally know the hurdles, being a physician who has been finding ways to bridge my holistic health interests with the medical world for almost two decades. From the skeptic looks to closed-minded views, doctors can seem to be an intimidating bunch, but there are always those who are willing to open their perspectives to complementary ways of serving patients.

This is the first of a four-part series of articles on ideas for approaching networking with medical providers in your locale.

Part 1: WHO You Serve and HOW Your Skills Benefit Them

When thinking about where to even begin with the healthcare networking process, it can be very helpful to develop a deep understanding of the populations you serve.

If You Already Have a Target Demographic

Perhaps you may have already developed your own niche of clientele, a group of individuals you really enjoy working with. Maybe their common link has to do with social demographic characteristics, like children from low-resource neighbourhoods, female college athletes, or elderly nursing home communities. These social determinants help you to have a greater understanding of their potential health risks and conditions. Your yoga practice may be particularly tailored for them.

Alternatively, perhaps your practice is tailored to support individuals with specific health conditions such as scoliosis, addictions, or obesity. In this case, you may serve a diverse community of clients who share a common experience of illness.

In either scenario, you have likely developed keen expertise on the issues impacting the health of these populations, providing you with great insight to help tailor group classes and individual one-to-one sessions. As you consider where to start reaching out to medical providers, this understanding can help you to target healthcare practices that serve your niche communities. Maybe you will begin with a local community health center that serves inner-city youth or nearby pediatric clinics. Maybe you will reach out to Planned Parenthood centers or focus your outreach on OB/GYN practices.

If You Need to Pick a Target Demographic

If you happen to be a yoga teacher working with a wide variety of clients and/or perhaps are not bound to a particular niche, consider taking some time to research large medical practices you may want to reach out to in your community. Develop an understanding of the populations they serve. If practices do not have such information on their websites, consider giving them a call to find out a bit about their demographics. Otherwise, in the United States, you can often find a lot of health-related statistics about your region from your local county’s health department website. Community Health Assessments (like this one), conducted by each county across the country, are often published and include community-specific health improvement goals.   These reports can give you an overview of social characteristics and predominant health conditions influencing your potential client base.

Evidence Based Medicine

Once you have a well-developed understanding of the populations you may serve, it can be very helpful to familiarize yourself with the Evidence-Based Medicine (EBM) research on benefits of yoga, meditation, and mind-body modalities for the specific communities you work with. Familiarizing yourself with this support can help you to “make your case” when speaking with members of the medical community. Even being able to just cite 1-2 key studies that highlight benefits can often get uninterested ears perking.

The increasing popularity of yoga over the past three decades has ignited the scientific medical community’s interest in researching the benefits of yoga for health. You have likely been exposed to several studies supporting the use of yoga throughout your training with Yoga Medicine. Though the scientific literature base on yoga has been steadily growing, the quality and rigor of research studies have been mixed. Fortunately, there are resources that can help you sift through it all, including research compilation books that evaluate the data to date.

Dr. Gurjeet Birdee, MD, MPH, a physician-scientist and yoga therapist at Vanderbilt University suggests the new book, The Principles and Practice of Yoga in Health Care, edited by Sat Bir Singh Khalsa PhD, et al. “Yoga therapists and teachers often ask me about the evidence of yoga for specific conditions so they can cite the literature to clients and healthcare professionals such as physicians, “ says Dr. Birdee. He feels this book can be effectively used to find such references to support and validate clinical yoga practices. Chapters include overviews of conditions, surveys of literature, clinical considerations and insights from practicing yoga therapists and teachers.

Beginning to Craft Your “Elevator Pitch”

Using the information gathered above, you can start to artfully create your “elevator pitch” of sorts. Knowing your target communities, the health conditions they face, contributing factors, and EBM support for yoga in their healing journey, you can begin to tell the story of WHO you can serve and HOW your skills will help them nurture their health.

Join me in next installment of this series as we explore more approaches to support Yoga Medicine teachers looking to segue into the medical world. Namaste.

How Medications and Yoga Interact

A message from Tiffany:

I am excited to share this fantastic resource from one of our teachers – Margeaux Amerine. Margeaux has generously shared a reference chart she developed for the interactions between medications and yoga practice. Possible issues include dizziness, risk of falls, blood clotting and more.

Click here to view or download the chart for reference as you work with yoga clients.

About the Author

Margeaux graduated with her Doctorate in Pharmacy in 2008 from the University of Iowa College of Pharmacy in Iowa City, Iowa. She began practicing yoga the same year to help heal emotionally and physically after the loss of her father. Through the years yoga has remained an outlet in her life for growth and healing. In 2014, she completed her RYT-200 training with Yoga Medicine and is currently in the process of completing her RYT-500 with Yoga Medicine. She is a full-time practicing pharmacist and yoga teacher living on Whidbey Island, WA.

Connect with Margeaux on Instagram and Facebook.

Yoga for Chronic Disease Management

Rebecca Powell-Doherty, Ph.D. discusses how yoga can play a role in the management of chronic disease. Learn how the science backs up yoga for pain management, psychological outlook, and mobility in the chronically ill.

Yoga for Chronic Disease Management

Previously in this series, we’ve taken a close look at the benefits of yoga and, specifically, yogic breathing for stress management and short-term wound healing. While yoga practitioners are experiencing these benefits every day, the scientific understanding of how all this works is just starting to grow. However, there’s one area of yogic benefit where the literature, at least in terms of recognition, is actually quite prolific: chronic disease. Studies on everything from heart disease to chronic back pain to ulcerative colitis have explored yoga’s impact.

However, I’d like to focus on a subsection of this and carefully explore how yoga impacts diseases that have an autoimmune component; that is, diseases that stem from the immune system attacking its own body. This includes diseases such as rheumatoid arthritis (RA), Crohn’s disease, Multiple Sclerosis (MS), and many others.

Chronic Disease

For those living with these kinds of diseases, the reality is often chronic pain, fatigue, impaired mobility and neurological dysfunction, dietary restrictions, and unsettling and/or embarrassing symptoms. Living in this way day in and day out also increases the likelihood that these individuals may experience anxiety, depression, and decreased social interaction. Now, depending on the disease, there are a great many therapies offered by modern medicine that can help control or alleviate any variety of disease-associated symptoms. However, even in the most well-managed scenario, flare-ups do occur, and it can often be difficult to get things back under control. While yoga is not a cure or even a management plan by itself, the scientific evidence is mounting that it can benefit in conjunction with medical therapies.

Exciting Research

Understandably, the vast majority of the literature in this area focuses on diseases such as RA and MS: diseases with a movement component, regardless of the underlying pathology. For example, a review and meta-analysis from back in 2013 (Musculoskelet Care 11(2013):203-2017) examined seventeen different studies that looked at the effects of yoga for lower back pain (cause unspecified), RA, and fibromyalgia. In all cases, yoga significantly improved pain outcomes and evaluations of psychological perspective. In addition, more tangible functional outcomes (such as grip strength and range of motion indicators) were measured in numerous studies, and while the results were not always significant, mild to moderate improvements were seen in yoga participants across the board.

It’s exciting to note that this analysis looked at multiple systems and styles of yoga (Hatha, Iyengar, Viniyoga, etc), and the style of choice didn’t really matter. Couple this kind of evidence with a solid RCT, and suddenly we’ve really got something! Naturally, several investigators did just that. Back in 2011, Telles et al (BMC Research Notes (2011) 4:118) showed improvements in rheumatoid factor levels (a biomarker of active RA) after a single week of yoga intervention, and Moonaz et al (J Rheumatol (2015) 42(7): 1194-1202) showed long-term improvements (eight weeks and nine months) in flexibility, walking capacity, strength, and perceived quality of life in previously sedentary adults of all ages with RA or osteoarthritis.

More recently, just this year in fact, both Razazian (Med Sci Sports Exerc. 2016 May;48(5):796-803) and Dehkordi (J Clin Diag Res. 2016 June; 10(6):VC01-05) demonstrate that low impact exercise, such as yoga or swimming, is beneficial for fatigue, depression, pain, and controlling uncomfortable nerve sensations (tingling or burning) in individuals with MS, when combined with standard medications.

Conclusions

Now, as a yoga practitioner, you might be thinking that this sort of thing is obvious to you, and that may be absolutely true! However, medicine relies on peer-reviewed, scientific evidence like this to determine what is safe and beneficial for patients, which means studies like these are essential if we ever hope to fully integrate modalities like yoga and meditation into western medical thinking! We should also note that these studies focus on movement. This is unlike studies we’ve examined previously where breath work was the real requirement. None of it is particularly complicated, but getting on the mat or in the pool does seem to be the key. So if you’re struggling with something like RA or MS, consider working with your medical specialist and a knowledgeable yoga teacher to pick a style of yoga you love and find a routine that works for you.

Cheers, yogis!

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