When you think of the physical shape of Downward Facing Dog, what comes to mind? Do you think of a long upside-down V with the heels touching the ground and knees straight? That might be the way the shape looks on some people, but for many folks, downward dog can take many different forms - all of which are still accomplishing the same energetic purpose of this inversion posture.

Using the language customizing instead of modifying might help some patients realize they are not “doing less” by not being able to comfortably attain the physical shape of what they think they should be able to do. In fact, it is an opportunity to be rewarded for listening to one’s inner wisdom about how the body wants to move in that particular moment. We are not robots, and our bodies’ energy and pliability can change greatly during the day and from week to week, especially for people experiencing hormonally influenced persistent pain.

From a clinical perspective, customization emphasizes patient empowerment. For example, patients with pelvic pain often present with increased muscle guarding in the pelvic floor, hips, or abdominals. Asking them to force their heels to the floor or straighten their knees in Downward Facing Dog can increase tension and exacerbate symptoms. Instead, inviting them to bend their knees, widen their stance, or elevate their hands on blocks or a chair creates a version of the pose that is supportive and therapeutic. This allows patients to access the benefits of the posture - inversion, elongation, breath awareness—without reinforcing pain patterns.

As a small business owner, I’m grateful to have weathered the COVID-19 storm. When reflecting on the 5 year anniversary of the shutdown, I remember how we adapted day after day — masking up, running air filtration systems, and feeling grateful that we could continue to do our work safely. Yet, despite prioritizing sleep, nourishing my body with fresh food, staying active, and hydrating well, I sometimes still feel myself carrying a lingering undercurrent of stress and tension in my physical body.

We have spent years holding our breath—both literally and figuratively. The weight of collective uncertainty, change, and grief may have left some imprints on our bodies. I was reminded of this when a sudden flare of lumbopelvic pain forced me to pay closer attention to my own breath patterns. It became clear that I needed to soften, to release layer by layer of held tension, and to deepen my own breathwork and meditation practice.

As healthcare providers, our work extends beyond addressing physical concerns. We are honored to hold space for our patients' grief—whether it stems from physical trauma, medical challenges, gaslighting, or life's hardships.

Before we talk about yoga, let’s do a quick overview of interstitial cystitis/bladder pain syndrome.

In 2022, the American Urological Association updated the clinical guidelines on the treatment of interstitial cystitis/bladder pain syndrome. Prior to this revision, pelvic physical (and occupational) therapy was considered first-line treatment with evidence strength grade A. After this revision, the AUA recommends looking at the phenotype of the patient to determine which treatment categories would best serve the individual patient.

Three phenotypes have been identified: a bladder-centric phenotype, a pelvic floor phenotype, and a phenotype that experiences widespread symptoms with chronic overlapping pain conditions.

As musculoskeletal specialists, we are adept at identifying postural dysfunction. I often explain to patients how their ribcage might shift posteriorly relative to the plumb line and how gravity can amplify forces on specific structures. To help patients understand the difference between their habitual non-optimal posture and a more optimally aligned posture, many occupational and physical therapists use the IPA’s Vertical Compression Test (VCT). This test effectively demonstrates how improved alignment facilitates better weight transfer through the base of support. Sometimes this test reproduces back or pelvic pain which allows the patient to understand how their posture might be a contributing factor to them not feeling their best. In addition to the VCT, I incorporate Mountain Pose as an additional kinesthetic tool for postural retraining.

Many moons ago, I was working with a lovely client on embodied postural awareness using Mountain Pose. I suggested she could close her eyes if she felt comfortable (some people will feel safer lowering their gaze instead of closing their eyes). Working from the ground up, she realized her weight was predominantly in her heels. When I guided her to shift her weight forward by hinging from the talocrural joint, she experienced an “aha moment,” saying, “It feels like my pelvic floor just sighed.” She hadn’t been aware that her habitual posture involved standing with her weight behind the plumb line, which contributed to overactivity of the posterior pelvic floor. Once she adjusted her base of support from the ground up, she felt a significant release in her habitual tension.

At our follow-up visit, the client noted an increase in her postural awareness. She was surprised by how frequently she noticed her pelvic floor gripping in a state of overactivity. She also reported enhanced awareness during her standing yoga postures in class. Grounding down through the feet, cued as imagining the soles of the feet getting magnetically drawn into the floor, can be a useful verbal cue to assist with letting go of unnecessary gripping. The experience of achieving embodied optimal alignment has given her greater self-efficacy, and she’s successfully translated this improved postural awareness into her daily life. Self-awareness and empowerment are central goals in my physical therapy practice, and integrating yoga into this process makes my clinical work even more fulfilling.

B K S Iyengar describes pranayama as an “extension of breath and its control”¹. Pranayama, or breathwork, includes inhalation, exhalation, and breath retention. As clinicians treating pelvic health, there are several clinical applications for breathwork.

Mechanical relationship to the pelvic floor

Dustienne Miller, CYT, PT, MS, WCS instructed the H&W remote course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life.  You can find Dustienne Miller on Instagram at @yourpaceyoga

Research demonstrates multiple benefits of a yoga practice that extend beyond the musculoskeletal system. These benefits include improved mood and depression, changes in pain perception, improved mindfulness and associated improved pain tolerance, and the ability to observe situations with emotional detachment.

Do the brains of yoga practitioners vs non-practitioners look different?

Dustienne Miller is the creator of the two-day course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. 

I’m one of the small business owners who has survived this difficult time. Day after day I would mask up, put on the filtration systems, and be filled with gratitude that I could still safely do my work in the world. Despite being vigilant on sleep, eating lots of veggies from the local farm, exercising, and staying well hydrated I still carry a deep covering of stress and tension.

Dustienne Miller MSPT, WCS, CYT is a Herman & Wallace faculty member, owner of Your Pace Yoga, and the author of the course Yoga for Pelvic Pain. Join her in Columbus, OH this April 27-28, to learn how yoga can be used to treat interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. The course is also coming to Manchester, NH September 7-8, 2019, and Buffalo, NY on October 5-6, 2019.

How does a yoga program compare to a strength and stretching program for women with urinary incontinence? Dr. Allison Huang¹ et al have published another research study, after publishing a pilot study² on using group-based yoga programs to decrease urinary incontinence. Well-known yoga teachers Judith Hanson Lasater, PhD, and Leslie Howard created the yoga class and home program structure for this research study and the 2014 pilot study. The yoga program was primarily based on Iyengar yoga, which uses props to modify postures, a slower tempo to increase mindfulness, and pays special attention to alignment.

To be chosen for this study, women had to be able to walk more than 2 blocks, transfer from supine to standing independently, be at least 50 years of age, and experience stress, urge, or mixed urinary incontinence at least once daily. Participants had to be new to yoga and holding off on clinical treatment for urinary incontinence, including pelvic health occupational and physical therapy.

As practitioners, we understand the value of a yoga practice for multiple systems. Yoga improves cardiovascular function, pulmonary function, improves flexibility, builds strength, improves balance, and cultivates resiliency. Prenatal yoga is deemed safe and widely practiced. Beyond not laying prone after the first trimester, what are modifications for practicing yoga while pregnant? Is there any evidence to demonstrate if specific yoga postures are safe from both the maternal and fetal perspective?

Polis et al set out to determine the safety of specific yoga postures using vital signs, pulse oximetry, tacometry, and fetal heart rate monitoring. The patients were diverse in age, race, BMI, gestational age, parity, and yoga experience. Exclusionary criteria included preeclampsia, placenta previa, bleeding in the 2nd or 3rd trimester, gestational diabetes, BMI greater than 35 and other medical conditions that presented contraindications.

The maternal and fetal responses were tested in 26 yoga postures. The selected postures, much like most yoga classes, offered a variety of physical positions. The standing, seated, twists and balancing postures chosen were: Easy Pose, Seated Forward Bend, Cat Pose, Cow Pose, Mountain Pose, Warrior 1, Standing Forward Bend, Warrior 2, Chair Pose, Extended Side Angle Pose, Extended Triangle Pose, Warrior 3, Upward Salute, Tree Pose, Garland Pose, Eagle Pose, Downward Facing Dog, Child’s Pose, Half Moon Pose, Bound Angle Pose, Hero Pose, Camel Pose, Legs up the Wall Pose, Happy Baby Pose, Lord of the Fishes Pose and Corpse Pose.

You have been treating a highly motivated 24-year-old woman with a diagnosis of Interstitial Cystitis/Painful Bladder Syndrome (IC/BPS). The plan of care includes all styles of manual therapy, including joint mobilization, soft tissue mobilization, visceral mobilization, and strain counterstrain. You utilize neuromuscular reeducation techniques like postural training, breath work, PNF patterns, and body mechanics. Your therapeutic exercise prescription includes mobilizing what needs to move and strengthening what needs to stabilize. Your patient is feeling somewhat better, but you know she has the ability to feel even more at ease in their day to day. Is there anything else left in the rehab tool box to use?

Kanter et al. set out to discover if mindfulness-based stress reduction (MBSR) was a helpful treatment modality for (IC/BPS). The authors were interested in both the efficacy of a treatment centered on stress reduction and the feasibility of women adopting this holistic option.

The American Urological Association defined first-line treatments for IC/PBS to include relaxation/stress management, pain management and self-care/behavioral modification. Second-line treatment is pelvic health rehab and medications. The recruited patients had to be concurrently receiving first- and second-line treatments, and not further down the treatment cascade like cystoscopies and Botox.