(646) 355-8777

Herman & Wallace Blog

Using Yoga for Post-traumatic Stress Disorder

When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.

Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).

This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.

Cushing et al., (2018) recently published online a study testing the impact of yoga on post-9/11 veterans diagnosed with PTSD. The participants were >18 years old and scored at least 30 on the PTSD Checklist-Military version (PCL-M). They participated in weekly 60-minute yoga sessions for 6 weeks including Vinyasa-style yoga and a trauma-sensitive, military-culture based approach taught by a yoga instructor and post-9/11 veteran. Pre- and post-intervention scores were obtained by 18 veterans. Their PTSD symptoms decreased, and statistical and clinical improvements in the PCL-M scores were noted. They also had improved mindfulness scores and decreased insomnia, depression, and anxiety. The authors concluded a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms.

Domestic violence, sexual assault, and unimaginable military experiences can all result in PTSD. People in our profession and even more likely, the patients we treat, may live with these horrors in the deepest recesses of their minds. Yoga is gaining acceptance as an adjunctive therapy to improving the symptoms of PTSD. The Trauma Awareness for the Physical Therapist course may assist in shedding light on a dark subject.


Walker, J., & Pacik, D. (2017). Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Medical Acupuncture, 29(4), 232–238.
Cushing, RE, Braun, KL, Alden C-Iayt, SW, Katz ,AR. (2018). Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Military Medicine. doi:org/10.1093/milmed/usx071

Continue reading

Benefits of working with the breath

In his famous book Light on Yoga, B K S Iyengar describes pranayama as “extension of breath and its control”1.  Pranayama includes all aspects of breathwork: inhalation, exhalation, and breath retention.  As clinicians treating pelvic floor dysfunction, we emphasize the importance of breathing as a critical component of rehabilitation.  Physical therapists Paul Hodges (et al) and Julie Wiebe describe a piston-like relationship between the diaphragm and pelvic floor2,3.  Pranayama, or conscious breathing, can enhance this relationship, especially if there are holding patterns in the pelvis. On inhalation, the pelvic floor muscles and diaphragm move caudally. On exhalation, the pelvic floor muscles and diaphragm move cranially4.  As physical therapists, we instruct patients to use the breath in coordination with the pelvic floor muscles to obtain optimal stability and continence. 

 
Pelvic organ prolapse and urinary/fecal incontinence are often caused by a lack of tonic support and muscular strength of the pelvic floor, core and surrounding pelvic girdle musculature5.  Optimal pelvic floor support from adequate strength, core stability, and neuromuscular control allows for continence and organ support. For optimal core stability, there must be coordination and strength of all components of the deep core musculature – pelvic floor muscles, transverse abdominals, multifidi, and diaphragm6. The “Soda Pop Can Model of Postural Control”, conceptualized by Mary Massery, illustrates how the pressure system of an aluminum soda can maintains the stability of the structure7. Loss of support can happen at the top (i.e. tracheotomy), front (i.e. diastasis recti abdominus), back (i.e. disc herniation), or bottom (i.e. pelvic organ prolapse or incontinence). A “leak” in the structural integrity could affect postural control, core stability, and continence.  This concept underlines the importance of breath retraining as one aspect of our treatment plan.
 
Pranayama gives your patient a strategy to decrease sympathetic nervous system overactivity and encourages the parasympathetic response. According to Diane Lee, common areas of rigidity of movement/holding patterns include lateral and posterior-lateral expansion of the ribcage during inhalation8.  Mindful pranayama encourages the student to explore diaphragmatic breathing without gripping in the chest and ribcage.  
 

Examples of pranayama

 
Dirgha
Dirgha is the Three-Part Breath. Inhale, allowing the belly to fill.  If your patient finds this challenging, try a book on the belly when supine or try breathing in quadruped. The second part of dirgha is expanding the ribcage, followed by the collarbones to floating up. After trying this for 10 breath cycles, stop and recognize any new sensations or softening in the body. I recommend my patients set an alarm to go off every hour to remind them to move and breathe.
 

Ujjayi

Ujjayi is known as the Ocean breath. It sounds like you have one ear to a giant seashell. Raise one hand in front of the mouth and pretend to fog a mirror with an inhalation and exhalation.  Recreate the same action at the back of the throat, but now with the mouth closed. This breath should sound similar to the signature sound of the Star Wars villain Darth Vader.  Perform this breath with any warm-up or asana while layer this breath onto Dirgha.

 

Letting Go Breath

Letting Go Breath can be a great reset. Inhale through the nose. Gentle exhale with an audible sigh through the mouth. It’s a quick check in to access instant awareness to the areas in the body that habitually hold tension.

 

Integrating into the clinic

 

Depending on the patient, I may not reference the Sanskrit name of the pranayama in the clinic. If the client is seeking a private yoga session, the names of these pranayamas will come up. As always, I meet my patient where they are and don’t push or recommend yoga practices that they are not interested in.  

 

Breathwork can be performed supine while hooked up to biofeedback, sitting with their hands on their abdomen and chest, or standing moving their arms through abduction during inhalation. These examples are only the beginning of possibilities!

 

Dustienne Miller PT, MS, WCS, CYT teaches Pelvic Floor 1 and her two-day course Yoga for Pelvic Pain. Upcoming course date: September 16-17 in Somerset, NJ.

1) Iyengar BKS. Light on Yoga: Yoga Dipika. Schocken; 1995.
2) Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747.15.
3) Julie Wiebe, Physical Therapist | Educator, Advocate, Clinician. 2015; http://www.juliewiebept.com/.
4) Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-68.
5) Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3-12.
6) Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.
7) Massery M. THE LINDA CRANE MEMORIAL LECTURE: The Patient Puzzle: Piecing it Together. Cardiopulm Phys Ther J. 2009;20(2):19-27.
8) Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.

Continue reading

Upcoming Continuing Education Courses

Jun 28, 2019 - Jun 30, 2019
Location: Mount Carmel Health

Jun 28, 2019 - Jun 30, 2019
Location: Mizzou Physical Therapy-Rangeline

Jun 29, 2019 - Jun 30, 2019
Location: Advantage Physical Therapy

Jun 29, 2019 - Jun 30, 2019
Location: Vertex Physical Therapy Specialists

Jul 12, 2019 - Jul 14, 2019
Location: The Virginian

Jul 13, 2019 - Jul 14, 2019
Location: Johns Hopkins Medicine

Jul 19, 2019 - Jul 21, 2019
Location: Loyola University Stritch School of Medicine

Jul 20, 2019 - Jul 21, 2019
Location: East Sacramento Physical Therapy

Jul 21, 2019 - Jul 23, 2019
Location: Rutgers University - Doctoral Programs in Physical Therapy

Jul 26, 2019 - Jul 28, 2019
Location: Bon Secours St. Francis Health System

Jul 27, 2019 - Jul 28, 2019
Location: Providence Healthcare

Aug 9, 2019 - Aug 11, 2019
Location: Robert Wood Johnson Medical Associates

Aug 9, 2019 - Aug 11, 2019
Location: Metro West Medical Center

Aug 9, 2019 - Aug 11, 2019
Location: Providence Holy Cross Medical Center of Mission Hills

Aug 16, 2019 - Aug 18, 2019
Location: WakeMed Health & Hospitals

Aug 16, 2019 - Aug 18, 2019
Location: BodyWorx Vitality

Aug 16, 2019 - Aug 18, 2019
Location: Piedmont Healthcare

Aug 16, 2019 - Aug 18, 2019
Location: Dignity Health Care of Stockton, CA

Aug 17, 2019 - Aug 18, 2019
Location: Ochsner Health System

Aug 23, 2019 - Aug 25, 2019
Location: PeaceHealth Southwest Medical Center

Aug 23, 2019 - Aug 25, 2019
Location: Inova Physical Therapy Center

Aug 23, 2019 - Aug 25, 2019
Location: The Sage Colleges

Aug 23, 2019 - Aug 25, 2019
Location: Loyola University Stritch School of Medicine

Aug 23, 2019 - Aug 24, 2019
Location: Mizzou University of Missouri

Aug 23, 2019 - Aug 25, 2019
Location: Mizzou University of Missouri

Sep 6, 2019 - Sep 8, 2019
Location: Advanced Physical Therapy of Little Rock

Sep 6, 2019 - Sep 8, 2019
Location: Bon Secours St. Francis Health System

Sep 7, 2019 - Sep 8, 2019
Location: Franklin Pierce University

Sep 7, 2019 - Sep 8, 2019
Location: Spooner Physical Therapy

Sep 13, 2019 - Sep 15, 2019
Location: Huntington Hospital