Thriving in Healthcare: How pranayama, asana, and dyana can transform your practice Melissa Lea-Foster Rietz, FNP-BC, BC-ADM, RYT-200 Presbyterian Medical Services Farmington, NM [email protected]

Professional Disclosure I have no personal or professional affiliation with any of the resources listed in this presentation, and will receive no monetary gain or professional advancement from this lecture.

Talk Objectives — Provide a VERY brief history of yoga — Define three aspects of wellness: mental, physical, and social. — Define pranayama, asana, and dyana. — Discuss the current evidence demonstrating the impact of pranayama, asana, and dyana on mental, physical, and social wellness. — Learn and practice three techniques of pranayama, asana, and dyana that can be used in the clinic setting with patients. — Resources to encourage participation from patients and to enhance your own practice.

Yoga as Medicine — It is estimated that 21 million adults in the United States practice yoga. In the past 15 years the number of practitioners, of all ages, has doubled. — It is thought that this increase is related to broader access, a growing body of research on the affects of the practice, and our understanding that ancient practices may hold the key to healing modern chronic diseases. Yoga: A VERY Brief History — Yoga originated 5,000 or more years ago with the Indus Civilization — Sanskrit is the language used in most Yogic scriptures and it is believed that the principles of the practice were transmitted by word of mouth for generations. — Georg Feuerstien divides the history of Yoga into four catagories: — Vedic Yoga: connected to ritual life, focus the inner mind in order to transcend the limitations of the ordinary mind — Preclassical Yoga: Yogic texts, Upanishads and the Bhagavad-Gita — Classical Yoga: The Yoga Sutras of Patanjali, the eight fold path — Postclassical Yoga: Creation of Hatha (willful/forceful) Yoga, incorporation of the body into the practice Modern Yoga — Swami (master) Vivekananda speaks at the Parliament of Religions in Chicago in 1893. — In 1920 Paramahansa Yogananda arrives in Boston and establishes the Self-Realization Fellowship — Indra Devi, also known as the “First Lady of Yoga”, brought Hatha Yoga to her Hollywood Yoga studio in 1947. — Yogi Bhajan broke with tradition in 1969 and began to teach Kundalini Yoga to students in the United States. — Yoga is not restricted by Religion and includes number of leaders who champion nonviolence and peace; including the Dalai Lama. — Last year India’s prime minister Narendra Modi declared June 21st International Yoga Day, 190 countries agreed to recognize the day, highlighting the popularity of the practice. Three Areas of Wellness: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” — Mental: our ability to open our minds up to new ideas and experiences, to improve skills and seek challenges. — The World Health Oranization defines mental health as, “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” — Social: our ability to relate and connect with others, to establish and maintain positive relationships — Social health involves your ability to form satisfying interpersonal relationships with others. It also relates to your ability to adapt comfortably to different social situations and act appropriately in a variety of settings. — Physical: our ability to move through our day without undue fatigue or physical stress, recognizing that our daily habits have a significant impact on our level of wellness. — Components of physical health include activity, nutrition, substance use, rest, and sleep Pranayama

"Your breath is the bridge that leads you into the vibrational dimension of your being. When things get challenging, stop, slow down and breath." ~Panache Desai

“Breath is the bridge which connects life to consciousness, which unites your body to your thoughts. Whenever your mind becomes scattered, use your breath as the means to take hold of your mind again.” ~Thich Nhat Hanh

EBP Impact on Wellness — Studies have demonstrated that pranayama practices may: — Decrease anxiety and depression — Increase happiness — Improve overall quality of sleep — Improve our response to traumatic events — Activate the parasympathetic nervous system leading to enhanced mental health — Cardiovascular health — Increase in diaphragmatic excursion Nadi (channel) Shodhana (cleaning)

1) Sit comfortably with your spine erect and shoulders relaxed. Keep a gentle smile on your face. 2) Place your left hand on the left knee, palms open to the sky or in Chin Mudra (thumb and index finger gently touching at the tips). 3) Place the tip of the index finger and middle finger of the right hand in between the eyebrows, the ring finger and little finger on the left nostril, and the thumb on the right nostril. We will use the ring finger and little finger to open or close the left nostril and thumb for the right nostril. 4) Press your thumb down on the right nostril and breathe out gently through the left nostril. 5) Now breathe in from the left nostril and then press the left nostril gently with the ring finger and little finger. Removing the right thumb from the right nostril, breathe out from the right. 6) Breathe in from the right nostril and exhale from the left. You have now completed one round of Nadi Shodhan pranayama. Continue inhaling and exhaling from alternate nostrils. 7) Complete 9 such rounds by alternately breathing through both the nostrils. After every exhalation, remember to breathe in from the same nostril from which you exhaled. Keep your eyes closed throughout and continue taking long, deep, smooth breaths without any force or effort. http://www.banyanbotanicals.com/info/ayurvedic-living/living-ayurveda/ yoga/nadi-shodhana-pranayama/ Studies Demonstrate… — Decreases blood pressure — Increases skin conduction — Enhances immune function — Improves simple problem solving skills

IMMEDIATE EFFECT OF ‘NADI -SHODHANA PRANAYAMA’ ON SOME SELECTED PARAMETERS OF CARDIOVASCULAR, PULMONARY, AND HIGHER FUNCTIONS OF BRAIN N.K. Subbalakshmi1, S.K. Saxena2, Urmimala2, and Urban J.A. D’Souza Department of Physiology, Kasturba Medical College, (MAHE) Mangalore, India,2Department of Physiology, Sikkim Manipal Institute of Medical Sciences, Gangtok, India, and 3Department of Physiology, School of Medicine, University Malaysia Sabah, 88999 Kapalabhati (cleaning breath) 1) Sit comfortably with your spine erect. Place your hands on the knees, palms open to the sky. 2) Take a deep breath in. 3) As you exhale, pull your stomach. Pull your navel in back towards the spine. Do as much as you comfortably can. You may keep your right hand on the stomach to feel the abdominal muscles contract. Pull the navel in. 4) As you relax the navel and abdomen, the breath flows into your lungs automatically. 5) Take 20 such breaths to complete one round of Kapal Bhati pranayama. 6) After completing the round, relax with your eyes closed and observe the sensations in your body. 7) Do two more rounds of Skull Shining breathing technique (Kapal Bhati pranayama). http://sadhukalayoga.com/wp-content/uploads/2015/08/Kapalbhati-2.png Studies Demonstrate — Reduction of perceived stress — Beneficial effect on cardiovascular parameters — Reduction in body mass index — Improvement in pulmonary function testing (see study below) EFFECT OF 6 WEEKS OF KAPALABHATI PRANAYAMA TRAINING ON PEAK EXPIRATORY FLOW RATE IN YOUNG, HEALTHY VOLUNTEERS Dinesh T 1, Gaur G S2, Sharma V K3, Madanmohan4 , Harichandra Kumar KT 5, Grrishma B6 1Dinesh T, Assistant Professor, Department of Physiology, Vinayaka Mission’s Medical College, Karaikal- 609605 2Gaur G S, Additional Professor, Department of Physiology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry- 605006 3Sharma V K, Assistant Professor, Department of Physiology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry- 605006 4Madanmohan, Professor & Head, Department of Physiology, Mahatma Gandhi Medical College and Research Institute, Puducherry - 607 402 5Harichandra Kumar KT, Lecturer, Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry- 605006 6Grrishma B, Assistant Professor, Department of Physiology, Yenepoya Medical College, Mangalore-575018

Ujjayi (victorious) “Ujjayi Pranayama is a balancing and calming breath which increases oxygenation and builds internal body heat.” —Krishnamacharya

1) To begin your practice, find a comfortable seat. Lengthen your spine and relax your shoulders. 2) Inhale through your nose, then open your mouth to exhale slowly as if you’re trying to fog a mirror. Try to create a slight contraction at the back of your throat and listen for a long "HA" sound. 3) Try this several several times, in through your nose and out through your mouth, before you try closing your mouth and exhaling through the nose with the same effect. Begin to direct the breath slowly across the back of your throat for both your inhale and exhale. Ideally, this will create a soft and audible hissing sound as you breathe.

Studies Demonstrate — Decrease heart rate — Decrease systolic and diastolic blood pressures — Increase oxygen saturation — Reduces anxiety

CARDIOVASCULAR AND RESPIRATORY EFFECT OF YOGIC SLOW BREATHING IN THE YOGA BEGINNER: WHAT IS THE BEST APPROACH? Heather Mason,1 Matteo Vandoni,2 Giacomo deBarbieri,3 Erwan Codrons,2 Veena Ugargol, 4 and Luciano Bernardi2,3 1Department of Neuroscience, Roehampton University, London, UK 2Department of Public Health and Neuroscience, University of Pavia, Pavia, Italy 3Department of Internal Medicine, University of Pavia and IRCCS San Matteo, Pavia, Italy 4Department of Psychology, The Open University, London, UK Asana

Yoga is the fountain of youth. You’re only as young as your spine is flexible. ~Bob Harper

Yoga is not about touching your toes, it is what you learn on the way down. ~Jigar Gor

EBP Impact on Health ü Chronic Low Back Pain ü Endocrine Disorders ü Depression ü Elderly: balance, gait, decreased fall risk ü Pain ü Stress Management ü PTSD ü Pulmonary Function ü Cardiovascular Disease ü Headaches Pain Reduction — A 7-day study on 80 patients with chronic low back pain who participated in specific asanas and pranayamas, resulted in a decrease in anxiety, depression, and improvement in spinal mobility. Tekur, Chametcha, Hankey, & Nagendra, 2012.

Is yoga effective for pain? A systematic review of randomized clinical trials Posadzki, Paul et al. Complementary Therapies in Medicine , Volume 19 , Issue 5 , 281 - 287

Endocrine Disorders Journal of Diabetes Research Volume 2016 (2016), Article ID 6979370, 23 pages http://dx.doi.org/10.1155/2016/6979370 Review Article Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials Kim E. Innes1,2 and Terry Kit Selfe1,2 1Department of Epidemiology, West Virginia University School of Public Health, Morgantown, WV 26506, USA 2Center for the Study of Complementary and Alternative Therapies, University of Virginia Health System, Charlottesville, VA 22903, USA Received 2 June 2015; Revised 19 August 2015; Accepted 26 August 2015 Academic Editor: Mitsuhiko Noda Mechanism of Action — Reduce reactivity and activation of the HPA axis, which is implicated in an increased risk for DM2. — May shift the autonomic nervous system balance from primarily sympathetic to parasympathetic. Parasympathetic activation and autonomic balance are strongly linked to a decreased risk for DM2. — Neuroimaging research suggests specific brain structures may be activated which favorably change balance and mood. May increase resilience to stress, believed to improve outcomes linked to DM2. — May improve self-care, health-related attitudes, and lifestyle choices as a source of social support. Mental Health — Depression: considered an ancillary treatment option for patients with depressive disorders. — Sleep: Regular yoga practice (twice weekly for 50-60 minutes) was shown to improve sleep quality and lower work stress. — PTSD: 10 sessions of yoga significantly decreased PTSD symptoms. — Stress: A systematic review of the literature revealed positive effects on stress reduction in health adult populations. A total of 862 studies were extracted from the literature, 8 fulfilled the selection criteria for the review. Mechanism of Action J Altern Complement Med. 2015 Sep;21(9):530-8. doi: 10.1089/acm.2014.0044. Epub 2015 Jul 16.

Regular Yoga Practice Improves Antioxidant Status, Immune Function, and Stress Hormone Releases in Young Healthy People: A Randomized, Double-Blind, Controlled Pilot Study.

Lim SA1, Cheong KJ1. Balance & Mobility in the Elderly Age Ageing. 2016 Jan;45(1):21-9. doi: 10.1093/ageing/ afv175. Epub 2015 Dec 25.

Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis.

Youkhana S1, Dean CM1, Wolff M2, Sherrington C3, Tiedemann A3. Cardiovascular Conditions

Altern Ther Health Med. 2014 Mar-Apr;20(2):32-59.

Yoga and hypertension: a systematic review.

Tyagi A, Cohen M. http://www.clevelandclinicwellness.com/DailyDose/Lists/Photos/2013August/seatedfanposeintrmd.jpg Fan Pose — Alignment Points: Sit tall at the front edge of your chair with your feet set firmly on the floor. Make sure your back is off the chair. Watch to make sure your spine is not curled. Your heart is at center with your chin moving forward. Your shoulder blades are pulled back. If shoulders are tight or there is pain in the shoulders, keep your arms low on the chair. Benefits of Pose: This simple pose works as a heart opener. Stimulates immune system. Opens upper respiratory muscles. Stretches shoulders and arms. Increases awareness of the action of the shoulder blades. Aids in digestion and stretches belly. — http://health.clevelandclinic.org/2015/09/12-yoga-poses-can- work/ https://s3.amazonaws.com/yoga-assets/assets/content/articles/Y160_1.jpg Seated Mountain Pose — Alignment Points: Keep your spine in good alignment with head, neck and spine in one line. Tuck your chin in a bit and gently lift shoulders up, back and down the back. Keep knees in front of hips with your ankles under knees and all ten toes facing forward. Benefits of Pose: Increases awareness of posture overall, especially the spine. Strengthens all core muscles of torso and allows more space for organs to perform optimally. — http://health.clevelandclinic.org/2015/09/12-yoga-poses- can-work/ — Seated Mountain Pose Benefits: Mountain pose is sometimes called "samasthiti" or equal standing. This pose is often practiced at the beginning of a class and between poses as a way to reset and balance the body. The seated variation allows you to check in with your posture, release tension from the upper body, and focus on the breath while engaging the core.

Begin by sitting up straight in a chair. Roll your shoulder blades back and down, arms relaxed at your sides. Pull your bellybutton in to your spine to engage your abs, and keep your feet flat on the floor, if possible. Inhale through the nose and raise your arms overhead. Keep your arms shoulder width apart, and relax your shoulders. If you feel your shoulders creep up around your ears, relax them. Keep the belly strong, and gaze in between your hands, to the ceiling.

Stay here for five breaths. — http://www.sparkpeople.com/resource/fitness_articles.asp? id=1822&page=2 https://myhealth.alberta.ca/Health/_layouts/15/healthwise/media/medical/hw/h9991891_001.jpg Seated Side Bend — Alignment Points: Make sure your back is off of the chair. Sit tall and place one hand firmly into the cushion of the chair for stability. Lift the opposite arm up and over. Watch to make sure there is no sinking in the arm or spine. Benefits of Pose: Aids in respiration. Stretches rib cage and lengthens side body. — http://health.clevelandclinic.org/2015/09/12-yoga-poses- can-work/ http://res.cloudinary.com/hkc7v05ll/image/upload/ v1431358359/w6iehzt9xgawfqwzcviq.jpg Seated Cat/Cow — Benefits: This complementary pair of poses stretches the entire spine and improves spinal mobility. By arching the back in "cow" pose, you stretch the front torso and chest. In rounded-back "cat" pose, you help to stretch the back of the torso and shoulders. If you have any neck or cervical spine issues, keep the neck in line with the torso throughout these poses.

Begin by sitting up straight in a chair. Roll your shoulder blades back and down, arms relaxed at your sides. Pull your bellybutton in to your spine to engage your abs, and keep your feet flat on the floor, if possible. As you inhale, arch your back (leading with the chest) and look up toward the ceiling. Lift the chin and allow your arms to relax next to you. As you exhale, round your spine and let your head drop forward. Tuck the chin and allow your shoulders to roll.

Repeat five times, moving fluidly from cat to cow with each breath. — http://www.sparkpeople.com/resource/fitness_articles.asp? id=1822&page=2 Dyana

"Meditation is not sitting down and closing the eyes. Meditation is seeing and reaching what is beyond the limited self. It gives a moment of beauty and bliss, where all you have is joy." -Yogi Bhajan

EBP Impact on Health — Increases Positive Emotions — Increases vagal tone — Decreases Chronic Pain — Decreases PTSD — Decreases Telomere length — Increases Compassion — Decrease in stress response — Improves cognition and activates parts of the brain responsible for memory Loving-kindness Meditation — Focuses on the development of goodwill, kindness, and warmth towards others and towards yourself. — Also called metta, is unconditional, inclusive love. — Metta is first practiced toward oneself; as it is difficult to love others without first loving ourselves. To begin, sit in a comfortable position and take in two to three deep, slow breaths. Imagine the breath moving through the center of your chest to the area of your heart. — Mentally repeat a phrase such as: May I be happy. May I be well. May I be safe. May I be peaceful and at ease. — After a period of time you begin to direct this to someone you care deeply for, a friend or family member and slowly repeat the following: May you be happy. May you be well. May you be safe. May you be peaceful and at ease. — You continue to extend the phrases out to your neighbors, to your co-workers, to those who may illicit feelings of anger or sadness, and to the world. Mindfulness-Based Stress Reduction — 8-week intensive training in mindfulness meditation — In addition to meditation, the program utilizes yoga to assist in reducing sedentary lifestyle patterns. — Started at the Stress Reduction Clinic at the University of Massachusetts Medical Center in 1979 by Dr. Jon Kabat-Zinn. These courses are now taught throughout the country by physicians, nurses, social workers, and psychologists. — Body Scan Guided Practice — Mindful Eating — One-Minute Breathing Space Mantra Meditation — The word mantra is believed to come from the root word meaning, “that which protects the mind.” — Sounds which are used as an object of concentration — The words used in mantra may be chanted out loud or internally. — Mantra can help to still the mind, and it is believed that a chosen mantra becomes associated to the qualities of the spoken deity. The repetition of a mantra may enable the mind to become more unified, attentive, and present. — Article on Transcendental Meditation in The Atlantic: Mantras Before Math Class — http://www.theatlantic.com/education/archive/2015/11/ mantras-before-math-class/412618/ Kirtan Kriya Research conducted by Dharma Singh Khalsa, M.D. at the Alzheimer’s Research & Prevention Foundation has revealed that this 12-minute exercise has the following implications on health: — Reverses memory loss — Improves sleep quality — Down regulates inflammatory genes — Improves psychological and spiritual well-being — Increases telomerase by 43% For additional information on this exercise go to: http://www.alzheimersprevention.org/research/12-minute- memory-exercise

Meditation Myths — I have to have an empty mind in order to meditate — I have to chant in a language I don’t understand and change my religion — I have to sit still, and I am not able to this because…. — I become very anxious when I sit and have nothing to do... — I am always thinking and in order to meditate you have to completely clear your mind — I am a very busy person and have no time to meditate as you have to do it for at least 60 minutes every day Meditation is about seeing clearly the body that we have, the mind that we have, the domestic situation that we have, the job that we have, and the people who are in our lives. It’s about seeing how we react to all these things. It’s seeing our emotions and thoughts just as they are right now, in this very moment, in this very room, on this very seat. It’s about not trying to make them go away, not trying to become better than we are, but just seeing clearly with precision and gentleness.

~Pema Chödrön Practice Pranayama

Kripala https://kripalu.org

Yoga Download http://www.yogadownload.com

Sounds True http://www.soundstrue.com

Apps

Pranayama Free

Breathing Zone

Prana Breath

Asana

Yogaglo https://www.yogaglo.com

Gaia http://www.gaia.com

DoYogaWithMe https://www.doyogawithme.com

Apps

Yoga Studio

Yoga.com

Yoga101, 201, 301

Dyana UCLA Mindfulness Awareness Research Center http://marc.ucla.edu/body.cfm?id=22

Tara Brach https://www.tarabrach.com

Umass Center for Mindfulness (MBSR) http://www.umassmed.edu/cfm/stress-reduction

Alzheimer’s Research & Prevention Foundation http://www.alzheimersprevention.org

Shambhala, Susan Piver http://www.shambhala.com/startherenow

Apps

Insight Meditation Timer Headspace

Take A Break Sattva-Let’s Meditate

Study Recommendations — Light On Yoga by BKS Iyengar — Bhagavad Gita — Yoga Anatomy by Amy Mathews — The Secret Power of Yoga: A Woman’s Guide to the Heart and Spirit of the Yoga Sutras by Nischala Joy Devi — Bringing Yoga to Life: The Everyday Practice of Enlightened Living by Donna Farhi — Yoga as Medicine: The Yogic Prescription for Health and Healing by Yoga Journal and Timothy McCall, MD