FeatureArticle Therapy Referral Guidelines for Healthcare Practitioners

By Timothy McCall, Leigh Blashki, Subodh Tiwari, John Kepner, and Loren Fishman that they be conscious and willing to take have, the number of sessions per week, part. Otherwise, patients with virtually any and length of time before revisiting the medical condition, whether bedridden or referring physician. If the referring physi- ambulatory, can do suitably adapted yoga. cian is knowledgeable about yoga therapy, he number of people practicing yoga the prescription may specify desirable continues to grow rapidly. Yoga ther- and/or contraindicated practices. apy is also becoming more popular both in healthcare and community set- Therapeutic yoga appears to be Ttings, increasing numbers of yoga thera- pists are being trained, and the research extremely safe. The strenuousness base in support of yoga therapy continues of the practice is titrated to each to grow stronger. Many healthcare providers are aware of the benefits yoga student. Beyond medical conditions, can bring patients, yet some remain unsure of how to include yoga in the treat- the yoga therapist factors in the ment plan, the nature of a yoga therapy consultation—or even how to refer a client's overall level of fitness, patient to a yoga therapist—and what to stamina, frailty, and specific needs expect from yoga therapy. Yoga thera- pists, in turn, may be unsure how to inter- and desires for therapeutic act with the medical profession. This arti- cle is intended to advise both interested outcomes. clinicians and the yoga therapists they interact with. What is Yoga Therapy?

Yoga therapy is the use of various yoga practices—such as poses, relaxation tech- niques, breathing exercises, and medita- tion—to help people with a wide variety of Photo Credit: Maria Moreira, courtesyYoga of Therapy The and Simply Holistic Yoga Health Institute for health conditions, both physical and psy- chological. It can be a useful adjunct to medical care or, in some cases, can be Typically, private yoga therapy consulta- When advising patients, it is important used in place of conventional approaches tions include the following: to differentiate between a general yoga like drug therapy or surgery. class conducted by a yoga teacher and 1. Conducting an intake interview and/or yoga therapy, whether individual or in a Yoga therapy is often done through reviewing an intake form along with group. In developing a referral network, individual consultations. In this way, it is reports from healthcare practitioners that healthcare practitioners are encouraged to similar to other healthcare modalities. include current treatment, including speak with those in their locality promoting However, yoga therapy can also be pro- medications themselves as yoga therapists, evaluating vided in group settings in which partici- 2. Assessing the current health condition their training, competence, experience, pants have a similar condition and/or seek based on yoga therapy principles willingness and ability to communicate, similar therapeutic outcomes. In one-on- 3. Identifying underlying causes of the pre- and trustworthiness. one settings, the level of assessment can senting condition from the yoga therapy be detailed, allowing for a tailored treat- perspective Although yoga therapists are not ment plan to suit the client. In group yoga 4. Setting priorities and treatment strategy licensed and the term “yoga therapist” is therapy sessions, however, the level of in consultation with client not protected, reputable third-party cre- assessment is generally limited and the 5. Developing and implementing the yoga dentials are starting to emerge. Currently, treatment plan less individual. In either therapy program, which may include healthcare practitioners may search the case, the yoga practices may be modified dietary and lifestyle advice websites of the Australian Association of to make them safer or more accessible to Yoga Therapy Referrals Yoga Therapists (in Australia and New clients who may be frail or for whom Zealand), the Complementary and Natural standard yoga practices may be Healthcare Registry (in the United King- contraindicated. A yoga therapy prescription by a physician dom), and the Council on Yoga Accredita- (or other healthcare professional) looks tion (International) for yoga therapists Since the patients themselves must do the much like a physical or occupational thera- qualified by these organizations. By the practices to gain any benefits, all that is py referral. It should include diagnosis, latter part of 2016, a listing of yoga thera- required for successful yoga therapy is goals of therapy, cautions about special pists certified by the International Associa- conditions that the patient has or might

18 YogaTherapyToday | Winter 2016 www.iayt.org Feature Article continued tion of Yoga Therapists (IAYT) should be need to be aware of the potential interac- Healthcare providers do not need to available on the IAYT website. tions of yoga practice and drug therapy. have an in-depth understanding of yoga to For example, diuretics as well as many make skillful referrals to yoga therapists. Although yoga therapists do receive drugs with anticholinergic properties Since many practices that might seem to some education in basic biomedical termi- increase the risk of orthostatic hypoten- be contraindicated can be safely adapted nology and pathophysiology and may fur- sion, which could present a problem to to meet the needs of individual students, ther educate themselves to communicate students quickly rising from the floor or and since different yoga approaches vary better with healthcare providers, simplicity coming out of or . enormously, it is generally not incumbent on the part of the healthcare provider Anticoagulants increase the risk of hemor- on the referring clinician to specify which when making referrals is highly desirable. rhage in the event of a fall, which would yoga tools to avoid. Rather, if the referring Complex reports should be summarized in alter what a therapist would recommend. clinician provides general guidelines about basic language. Patients may be more his or her concerns, the yoga therapist likely to make an appointment with a yoga It is not uncommon that when people can figure out which practices should be therapist and commit to the advice given if begin to practice yoga regularly their need omitted or modified. For example, in a their healthcare practitioner provides a for medication decreases. The change patient with diabetic retinopathy, the yoga specific referral, rather than simply generally happens gradually over weeks therapist could be advised to avoid any advising the patient to seek out a yoga to months but could occur sooner if the practices that increase intraocular therapist. students ramp up their practices quickly. pressure. The greatest risk in this regard are drugs Final Thoughts Yoga therapy usually involves a num- that lower blood pressure or serum glu- ber of consultations with the yoga thera- cose levels, risking syncope and hypo- pist. Follow-up sessions allow the thera- glycemia, respectively. Therapists must A common challenge in yoga therapy is pist to refine the plan, make sure what the focus their serial patient evaluations on patient compliance. A few words from the student has been practicing is being done these possibilities and send their clients referring clinician may help motivate in an appropriate way, and to address any back to the referring physician, or at the patients to continue their yoga program. It new concerns that may have arisen in the very least, call the physician if changes is also important that patients be reminded interim. In the process of teaching the rou- are detected or strongly suspected. that yoga therapy is usually an adjunctive tine to the client, the therapist will some- therapy and that they should continue with times determine that the regimen as If the patient takes analgesics, anti- their other treatments under the care of planned is not quite right and will make inflammatory drugs, or similar medications their healthcare practitioners. It is the modifications. Whenever possible, details for arthritis or another painful condition, responsibility of both the yoga therapist of the yoga evaluation and plan should be adjustments might be advisable in either and the referringYTT clinician to reinforce this shared with the referring clinician. the drug schedule or time the patient prac- message. tices to allow therapeutic blood levels to The Principles and Practice Yoga therapy consultations are typi- be optimal during yoga. Any exercise, ofAdapted Yoga in from Health Care cally several days to a few weeks apart including yoga, can bring on asthma , edited by and the client is provided with a program attacks in susceptible individuals. If Sat Bir Khalsa, Lorenzo Cohen, Timothy of yoga therapy recommendations to prac- patients use an inhaled bronchodilator, McCall, and Shirley Telles (Handspring tice (at home, work, or elsewhere). The advise them to use it approximately 15 Publishing, January 2016). program may be written, photographed, or minutes before starting their practice. provided as audio or video recordings to Contraindications and Cautions in Timothy McCall, MD, support the patient. Many clients have Yoga Therapy is an internist, yoga three or four consultations over a number therapist, author, of weeks. In some instances, a healthcare and director of practitioner and yoga therapist may As with any healthcare intervention, a cli- Yoga As Medicine believe that a patient is best served by nician should weigh the risks versus the Seminars and regular therapeutic sessions, possibly benefits of yoga therapy. Therapeutic Teacher Trainings at meeting once a week over a number of yoga, as opposed to general yoga class- the Simply Yoga months. es, particularly vigorous ones, appears to Institute for Yoga be extremely safe. In contrast to most Therapy and Holistic When yoga therapy is being contem- classes, in yoga therapy the strenuous- Health. Leigh Blashki plated, it is important to consider what ness of the practice is titrated to each stu- is a yoga therapist other treatments may already be part of dent. Beyond medical conditions, the yoga and the founder of the Australian Institute the treatment plan. For example, a patient therapist factors in the client's overall level of Yoga Therapy, the president of Yoga may be receiving physical therapy for a of fitness, stamina, frailty, and specific Australia, and a member of the IAYT musculoskeletal injury, part of which needs and desires for therapeutic out- Certification Committee. Subodh Tiwari is includes prescribed stretching. The yoga comes. the Joint Director-Administration of the therapy component of the treatment plan Kaivalyadhama Yoga Institute in Lonavla, needs to factor in these stretches to be Given the nature of yoga therapy as a Pune, India. John Kepner, MA, MBA, is a sure the programs don't counter each holistic mind-body practice, there are no yoga teacher and therapist and the execu- other or lead to overwork of a body part. overall contraindications to yoga therapy tive director of the International Associa- Therefore, in yoga therapy referrals, be per se. Not all yoga therapy involves phys- tion of Yoga Therapists. Loren Fishman, sure to mention what else is being done. ical postures () or breath work MD, is the medical director of Manhattan Interactions of Medication and (), although these practices are Physical Medicine and Rehabilitation, an Yoga Therapy Practice commonly a part of treatment strategies. It author, yoga teacher, and an assistant involves providing only what the client clinical professor at the Columbia College needs and is capable of practicing. of Physicians and Surgeons. Referring clinicians and yoga therapists www.iayt.org YogaTherapyToday | Winter 2016 19