“What happens in vagus..affects everything.” Understanding the polyvagal theory and how to apply in physical therapy practice. Micah Hilton, PT, DPT, OCS, CFE, PYT-c Kimberly Peters, PT, DPT, CSMT, PYT-c The need for change Traditional healthcare Empowering the patient ● Chronic pain is on the rise ● People are seeking a more ● Current healthcare system integrative approach ● Healthcare providers are looking for ways to provide intervention through biopsychosocial methods Learning Objectives ● Participants will have an understanding of key components of polyvagal theory and how these components relate to acute and chronic pain responses. ● Participants will have an understanding of treatment options in addressing stress response in order to reduce pain response in working with clients with acute and chronic pain. ● Participants will have an understanding of anatomy and physiology of the 3 diaphragms and system based effects we can impact. Autonomic Nervous System Anatomy and Physiology Sympathetic Nervous System Parasympathetic Nervous System ● Flight or fight system ● Rest and digest system ● Cell bodies in lateral horn of spinal cord ● Exit the CNS via CN 3,7,9,10 and S2-4 levels T1-L2 ● Vagus Nerve = 75% of the PNS ● Regulation of blood vessels ● Cardiac relaxation ● Role in immunity ● Digestion ● Active during inspiration ● Exhalation phase of respiratory cycle ● Neurotransmitters: Adrenaline (epinephrine), Cortisol Stress Response Acute Response: Multi-system Impact ● Dilated pupils, increase HR, awake and alert ● Larger muscles activate (run, protect), stabilizing muscles deactivate ● Blood is directed to important organs, energy stores mobilized ● Pain system is down regulated through perception of threat ● Decreased sexual function/interest ● Mood changes - anxious, nervous ● Increase respiratory rate, change in respiratory pattern Stress Response Long Term Response: Multi-system Impact ● Adrenal fatigue, difficulty sleeping ● Muscle imbalances, impaired balance and proprioception ● Memory changes, difficulty with focus and concentration ● Hyperalgesia, hypersensitivity, allodynia, nerve sensitivity, difficulty with left/right ● Immune deficiency, prolonged inflammation of tissues, old injury sites have increased sensitivity ● Low libido, infertility ● Difficulty finding words or less expressive ● Depression, mood swings, apathy, irritability, anger, frustration ● Altered respiratory pattern, decreased oxygenation of tissues ● Changes to digestion, weight changes, decreased or increased appetite Polyvagal Theory Key components ● Focuses on the vagus nerve and how it relates to our ability to connect and communicate ● The vagus nerve gives a bidirectional conduit between the brainstem and visceral organs ● The dorsal vagal circuit encompasses both the sympathetic and parasympathetic nervous systems, each contributing to either freeze mode or fight/flight modes with a neuroception of threat. ● The ventral vagal circuit uses the parasympathetic nervous system through neuroception of safety to activate the social engagement mode. Polyvagal Theory Relation to acute and chronic pain ● The perception of real or imagined threat activates the sympathetic nervous system and depresses parasympathetic nervous system, or vagal, influence. ● Vagal tone can influence exteroception, interoception and proprioception ● Pain is all about protection ○ Signs of safety cause our nervous systems to relax (parasympathetic) ○ Signs of danger cause our nervous systems to react (sympathetic) ■ Over reaction can lead to over sensitivity and persistent pain Diaphragmatic breathing and sound ● Anatomy and physiology of diaphragms ○ Abdominal diaphragm- main muscle of respiration ■ 3 anatomical connections at costal, sternal and lumbar ■ The 3 attachments also influence 2 other diaphragms, the thoracic and pelvic. ○ The diaphragm is the key connecting point of the two vagal pathways, and through sound, voice, facial expression and baroreceptor function. ○ Production of vocal sounds are neural exercises of the middle ear, which can influence social engagement via vagal regulation of the heart. Yoga and mindful movement ● Treatment options ○ Yoga or mindful movement can be used for many populations or diagnoses. ■ Used to decrease stress response ■ Demonstration of novel movement; non threatening ■ Improvement of neurodynamics ■ Stabilization and strength ■ Coordination ■ Pelvic floor dysfunctions ● Application in acute and chronic pain ○ Anatomical links between periaqueductal gray and default mode network ○ PAG: opiate rich area of the brain ■ Improvement of activation of PAG can aid in pain suppression ■ 3 minutes of diaphragmatic breathing and meditation a day can decrease inflammation in body Medical Therapeutic Yoga ● Views the whole person through a yogic ● Combines Ayurvedic clinical evaluation biopsychosocial model methods for analysis in yoga ● Establishes interdisciplinary integrative yoga ● Includes sound, music, and voice analysis education in healthcare therapy ● Recommends attention to breath prior to ● Teaches non-weight bearing headstands and teaching postures or movement non-cervical weight bearing shoulder stands ● Advocates for biopsychosocial stability as a and emphasizes protection of vulnerable primary focus with mobility as a secondary joints focus, guided by principles of ● Welcomes all disciplines of yoga and spiritual neurophysiology and biomechanics belief systems ● Informs dynamic execution of breath and ● Guides the student to seek the self pursuant postures via instruction of internal and to one’s duty/mission external support Let’s try it out Lab Learning Objectives ● Participants will demonstrate understanding of assessment of breathing patterns and recognize aberrant or compensatory breathing patterns. ● Participants will demonstrate understanding of using NAP meditation for reducing stress response. ● Participants will demonstrate understanding in teaching, educating, and performing relaxation techniques such as abdominal diaphragmatic breathing, 3 part/4 part breathing, vocalization, and mindful movement. Breath Assessment ● Observation ● Self awareness ● Breaths/min, chest expansion ● Abnormal breath patterns ○ Thoracic/Chest/Clavicular ○ Paradoxical ○ Mask ○ Open-mouth Breathing techniques Relaxation ● Abdominodiaphragmatic Breath (AD) ○ Inhale: allow the belly to expand ○ Exhale: allow the breath to leave through relaxation, returning the belly to resting position ● 3 part ○ Inhale: using AD breath, inhale from pelvis and lower abdomen, then lower ribs, then upper rib cage ○ Exhale: starting from upper rib cage, then lower ribs, then lower abdomen/pelvis ● Starting postures: yoga couch, supine with quarter fold, sidelying, supine with legs up wall or on chair Breathing Techniques Stability, Power ● Transversus abdominis-assisted thoracodiaphragmatic breath (TATD) ○ Inhale: expand through the lower ribs and diaphragm ○ Exhale: Draw the lower ribs toward each other, engage the TA by drawing up/in and activation of pelvic floor to create stability while maintaining spinal neutral ● Starting postures: yoga couch, hooklying with quarter fold, hero over blocks, prone Impacting 3 Major Diaphragms Cervicothoracic, Respiratory, Pelvic NAP Meditation N - Neutral larynx A - Apposition of diaphragm P - Pitch Sound ● Voice ○ Review: Production of vocal sounds are neural exercises of the middle ear, which can influence social engagement via vagal regulation of the heart ○ Vibratory input around the ears results in potential stimulation of auricular branch of the vagus nerve ○ Vocal toning/chanting can accomplish stimulation ■ Limbic deactivation found with chant/vocal toning of “om” ● Decreased reaction of amygdala ● Music ○ Music has been used therapeutically for thousands of years ○ Can cause release of opiate, oxytocin and dopamine from the brain’s natural “drug cabinet” The use of sound, breathing techniques, healing language, and education ultimately fosters self regulation and resilience of physiological function, emotion regulation and prosocial behaviors. Please join us for some breathwork and mindful movement Questions?? References ● Baron, R. and W. Janig (2004). The role of sympathetic nervous system in pain processing. The Pain System in Normal and Pathological States: A Primer for Clinicians. L. Villanueva, A. Dickenson and H. Ollat. Seattle, IASP Press. ● Baschetti, R. (2001). Chronic fatigue syndrome, decreased exercise capacity, and adrenal insufficiency. Archives of Internal Medicine, 161(12): 1558-1559. ● Butler, D. S., & Matheson, J. (2000). The Sensitive Nervous System. Adelaide Australia: Noigroup Publications. ● Cohen S, Gianaros PJ, Manuck SB. A Stage Model of Stress and Disease. Perspect Psychol Sci. 2016;11(4):456–463. doi:10.1177/1745691616646305 ● Dantzer, R. (2001). Stress, emotions and health: where do we stand? Social Science Information, 40(1), 61–78. doi: 10.1177/053901801040001004 ● Garner Ginger, “Dr. Ginger Garner: Polyvagal Theory and the Stress Response - Why Language Matters and Safety is Soverign” https://www.integrativepainscienceinstitute.com/latest_podcast/dr-ginger-garner-polyvagal-theory/, Integrative Pain Science Institute. Accessed 7/10/2019. ● Garner G. (2016). Medical Therapeutic Yoga: Biopsychosocial Rehabilitation and wellness Care. Pencaitland, United Kingdom. Handspring Publishing Limited. ● Garner Ginger, “Yoga for Stress Relief, Tapping into the Power of the Vagus Nerve” https://www.yogauonline.com/yoga-for-stress-relief/tapping-power-vagus-nerve-how-your-breath-can-change-your-relation