Restoring Homeostasis

Our bodies, our psyches and the ecosystems we inhabit have an innate ability to return to a balanced state. Change, upheaval, extreme conditions and the pull of various forces on our systems test their ability to return to center, to return home, to homeostasis. Here's a definition of homeostasis as applied to the body:

The tendency of the body to seek and maintain a condition of balance or equilibrium within its internal environment, even when faced with external changes. A simple example of homeostasis is the body's ability to maintain an internal temperature around 98.6 degrees Fahrenheit, whatever the temperature outside. (dictionary.com)

When you think about your own naturally healthy tendencies, you realize that balance is integral to a state of good health: we don't want too much or too little of any given quality, and all qualities working in harmony make up the whole of a healthy individual. There are many little actions we perform which have equal and opposite counterparts to keep us balanced: when we sweat we rehydrate, when we exert ourselves we rest afterwards, when we sit we feel the need to get up and walk around, when we feel cold we seek warmth. These equalizing actions are obvious, but there are also subtler mental balancing acts we perform to keep our lives balanced: when our lives are too predictable we seek out creative change, and in times of crisis or upheaval we find ways to anchor ourselves in comforting routines and sensations. When we feel stressed by mental challenge we can shut off our ruminative minds with a comforting daydream. There are so many maneuvers we employ, both physical and mental, to keep ourselves in an optimal state of homeostasis. 

In yoga practice, there is a concept of staying in balance called pratikriya, a Sanskrit word meaning counteraction, opposite action or remedial measure. For every yoga pose, there is a counter pose. For every existing or desired state of the mind/body, there are specific balancing techniques we use involving breath, movement, meditation and rest. Instead of a simple routine we mindlessly repeat, when we apply the concept of pratikriya, we pay attention to our need to stay balanced and structure our practice according to what we need each day. Within a yoga sequence, we use specific poses to compensate for any imbalance created by certain other poses. There is an art and a science to developing any yoga sequence.

Often in my sequencing of my own practice, and even in the classes I teach, pratikriya is intuitive as much as it is planned in advance. When I do a backbend I follow it with a pose to neutrally extend the spine, to rest, and then to fully counterbalance by forward bending. Sometimes I do these things simply because it feels better, and not because I am consciously thinking about pratikriya. 

I practice and teach restorative yoga because resting in restorative postures is the perfect counterbalance to leading a stimulating and physically active life. Restorative yoga is the Sabbath of yoga asana practice, the fraction of time I give my body to completely relax with awareness. I tend to skip my own restorative practice quite often, but I do teach one restorative class per week and can feel the balance it restores from teaching my more active classes. Restorative yoga is not for everyone. Some people feel that their lives are already too sedentary due to the nature of their work and lifestyle, and they feel most refreshed by an invigorating asana sequence in the one or two classes they make time for each week. Other people may be recovering from illnesses or dealing with what feels like an excessive amount of stress, and restorative practice feels right. Whether or not any particular form of yoga practice is beneficial depends entirely on the individual doing the practice. 

I invite you think about your own natural tendency toward homeostasis, and the methods you use in your life to apply pratikriya, in your yoga practice and in general. Make a habit of checking in with yourself week to week and choose the type of practice which will guide you back to your healthy center. 

Yoga as a Complementary Therapy for Rheumatoid Arthritis

The undisputed ubiquity of arthritis does not soften the blow of this crippling disease when it hits. Who hasn’t seen the toll arthritis takes on a loved one or a colleague, relentlessly chipping away at vitality sometimes in the prime of one’s life? As a registered yoga teacher (RYT), I can vouch for the prevalence of arthritis in the population where I live; fully one half of the students I teach have come to class reporting some form of arthritis, either doctor or self-diagnosed. A quick look at national statistics bears it out much better than anecdotal evidence could:

·         An estimated 52.5 million adults in the United States were told by a doctor that they have some form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia.

·         One in five (22.7%) adults in the United States report having doctor-diagnosed arthritis.

·         By 2030, an estimated 67 million Americans ages 18 years or older are projected to have doctor-diagnosed arthritis.

(Arthritis-Related Statistics. (2016). Retrieved March 14, 2016, from http://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm)

Seeing yoga students with arthritis improve over time with regular class attendance and home practice personally motivates me to learn about therapeutic applications for yoga in the treatment of arthritis. Rheumatoid arthritis (RA) interests me specifically, since I have a family member who has suffered for many years with RA, and, one of the more successful yoga teachers I know uses yoga as a powerful self-healing tool for her recently diagnosed RA.

Is there existing scientific evidence demonstrating my hunch that yoga is indeed beneficial as a complementary medical treatment for RA? The news is both good and bad: yes, there are recent and very promising preliminary studies pointing to yoga as an effective complementary treatment, but unfortunately the evidence base is limited and existing studies preclude drawing scientifically definitive conclusions (Haaz, Bingham, Wissow & Bartlett, 2015). It is currently safe to assert that yoga practice is, at the very least, feasible as a complementary approach for people with RA (Evans, Moieni, Taub, Subramanian, Tsao, Sternlieb & Zeltzer, 2010). Had certain improvements been made in the quality of the studies, particularly in their size, scope, normalization and transparency of intervention protocols, there would be no question remaining as to yoga’s proven efficacy in successfully treating RA (Haaz & Bartlett, 2011). The lack of definitive proof notwithstanding, those who suffer from RA can look to the most positive and consistent findings to date as encouragement to add yoga practice to their current treatment regimen for a generally improved outcome.

According to statistics from the Centers for Disease Control and Prevention (CDC), an estimated 1.5 million adults in the US suffered from RA in 2007. New evidence suggests a recent rise in the incidence of RA, specifically in females (Rheumatoid Arthritis Incidence on the Rise in Women, PubMed n.d.). Coincidentally, yoga practice among women in the US continues to increase; women with RA who are well enough to stay active are already choosing yoga as a therapeutic form of exercise (Bernstein, n.d.).

A particularly debilitating form of arthritis, RA is a chronic disease that significantly impacts quality of life (Evans, Moieni, Taub, Subramanian, Tsao, Sternlieb & Zeltzer, 2010). RA is “an inflammatory, autoimmune disorder resulting in a degeneration of the synovial lining in joints, making them swollen, stiff and less functional” (Telles & Singh, 2012).

RA impacts not only the joints, but the entire mind-body system, having a strong correlation with deteriorating mental health. As with other autoimmune disorders, previous studies have found that RA is associated with psychological stress (Telles & Singh, 2012). Increased stress hormones have been found in the blood of patients who developed rheumatoid arthritis and systemic lupus. In one study, people with post-traumatic stress disorder were found to have a higher risk of developing autoimmune disorders (Telles & Singh, 2012). Continued mental and emotional stress is known to worsen RA symptoms, and the pain experienced in the body as a result of the disease contributes to mental health symptoms such as depression and anxiety (Telles & Singh, 2012). According to data compiled by the CDC, arthritis (all types, not just RA) is strongly associated with major depression (attributable risk of 18.1%), linked to the patient’s experience of functional limitation. Nearly 7% of adults with arthritis report severe psychological distress (Arthritis Related Statistics, 2016).

Because of the prevalence and severity of all forms of arthritis among adults in the US and the resultant loss of functioning and lifestyle impairment, more people are seeking relief beyond what they have found through traditional medicine in complementary and alternative medicine (CAM). “CAM is a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine […] CAM practices may be grouped within five major domains: alternative medical systems, mind-body interventions, biologically-based treatments, manipulative and body-based methods and energy therapies. A survey released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health in the United States, found that in 2002, 36% of Americans used some form of alternative therapy in the past 12 months, 50% in a lifetime. Most people use CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain” (Tabish, 2008). Ayurveda, which originated in India more than 5,000 years ago, is an example of a complementary and alternative healing system; yoga, meditation, massage, diet and herbs are encompassed under the umbrella of Ayurveda, and all of these tools are being used in the complementary treatment regimens of RA patients.

Medical doctors are increasingly open to the CAM treatment trend for their patients suffering from the stress of chronic pain: “Rheumatologic conditions such as osteoarthritis, rheumatoid arthritis and fibromyalgia, provide an optimal disease framework for using CAM because these conditions are prevalent, have no known cause or cure, are characterized by chronic pain and variable disease course, and often adversely affect functional status” (Rao, 1999).

As a CAM therapy, yoga’s mind-body emphasis makes it especially suitable for the treatment of RA, since yoga provides concrete tools for addressing the co-occurring mental health challenges tied to RA’s autoimmune, inflammatory and pain-management components. Yoga practice trains people to internally focus their attention, “pinpointing the sources of pain or anxiety and learning to relax them” at will, and consciously (Bernstein, n.d.). Yoga therapy “involves marshalling multiple techniques that involve the mind, body and spirit. Treatment is individualized and dependent on the presenting symptoms” (Tabish, 2008).

Yoga as a tool to manage both musculoskeletal and mental symptoms of RA has shown promising effectiveness in eight different studies completed before 2012. “After reviewing the eight studies, the following points emerged: (i) each study indicated that yoga is a useful add-on therapy for treating RA, (ii) the studies all had limiting factors, (iii) the most significant benefits were observed when yoga was practiced in a combination of physical postures, regulated breathing, meditation, and yoga philosophy, and (iv) there have been no noteworthy attempts to explain the mechanisms underlying the changes observed. […] Sufficient evidence exists to suggest that yoga should be considered an add-on therapy for RA, but further research is necessary to account for limitations” (Telles & Singh, 2012).

For both yoga therapists and researchers who continue to blaze the trail of yoga as a complementary treatment for RA, it is useful to underscore the symptoms which have shown the greatest improvement under a yoga regimen. Fortunately, recent results from multiple studies have shown promise in addressing a broad array of RA symptoms. In Yoga for Arthritis: A Scoping Review, we find a summary of the most effective results up to 2011: “…the most consistent findings were for tender or swollen joints in persons with RA, which improved for all 3 studies that used this outcome. Another common outcome was pain, which improved in 6 out of 8 studies, measured by various tools. Disability improved in 3 out of 4 studies. Self-efficacy improved in both studies in which it was measured. Mental health and energy improved in 2 out of 3 studies. For grip strength, improvements were in seen in both studies of RA” (Haaz & Bartlett, 2011). One randomized controlled trial from 2015 analyzing yoga therapy outcomes in patients with osteoarthritis and RA aptly summarizes the comprehensive treatment outcome: Compared to a waitlisted group of participants, as early as the eighth week of Integral-based hatha yoga practice, “adjusted analyses showed yoga participants reported significantly less impairment on SF-36 role physical, body pain, general health, vitality, and mental health scales, with trends (p < 0.08) evident in physical function and role emotional” (Haaz, Bingham, Wissow & Bartlett, 2015). Specifically with respect to mental health symptoms, this study found that “the yoga group reported significantly fewer depressive symptoms (CES-D) and higher positive affect (PANAS).” Underlying this improvement could be the benefit of decreasing perceived pain, since the yoga group reported that their pain significantly improved. Furthermore, “yoga was associated with substantial improvements in physical and general health perceptions, physical roles, walking […], energy and mood. Regular yoga practice was not associated with worsening joint symptoms or adverse events;” specifically for the 25 RA patients included in the study, “swollen and tender joint counts decreased significantly with yoga”  and “PtGA scores improved” (Haaz, Bingham, Wissow & Bartlett, 2015). The authors believe that yoga’s particular effectiveness for treating arthritis can be explained by the combination of “physical activity with potent stress management techniques, including breathing, relaxation, and mindfulness.”

Moving forward from the successes of the studies cited above, those of us working with RA clients would benefit from agreement upon a generally applicable yoga intervention protocol which is readily adaptable to individuals. As has been previously noted, in prior studies using yoga to treat RA, “the styles, doses and format varied.” We need to agree on “the delivered intervention” making sure it is “population appropriate,” since “patients who have considerable musculoskeletal limitations and symptoms” require specific modifications (Haaz & Bartlett, 2011).

As a newer RYT (I’m a 3 year veteran), I have already noticed that too much too soon, for any yoga practitioner, can quickly lead to burnout and an abandonment of the practice of yoga, temporarily if not permanently. In the studies I reviewed for this project, several authors commented on the difficulty in keeping enough participants in programs which met very frequently (more than twice per week), due to scheduling conflicts. Certain of the studies under review in the journal articles cited above required the participants to do yoga daily for an extended period of time, in a controlled setting. Clearly, this sort of regimen would not be adaptable to most RA patients’ lifestyles. There are definite advantages to practicing in a group (camaraderie, encouragement) with a well-qualified teacher (safety, efficacy), however: I strongly believe that some of the greatest breakthroughs in healing are facilitated by home practice, with the yoga practitioner self-applying and adapting methods he/she has previously learned under a teacher. For these reasons, I suggest that RYTs and yoga therapists work with newer RA clients one-on-one or in a small group yoga class once per week on an ongoing basis, while helping the clients to create a safe and reliable home yoga practice they can repeatedly adapt according to their needs. This is, of course, the standard yoga therapy model widely used by most all yoga professionals. The clients who are willing and able to attend private or group sessions more regularly can choose to do so when appropriate, without feeling pressured to create more stress for themselves by constraining their schedules.

With respect to the content of the yoga sessions, given the preponderance of evidence, postural yoga alone is not an effective intervention for RA. The most effective tool to reduce stress and mental health symptoms is breath work; each session should begin and end with a focus on helping the client to connect to the healing power of regulated breathing. The postures should be introduced as therapeutic movement which is rooted in and facilitated by the breath. Meditation and relaxation techniques such as supported savasana and other restorative yoga postures should be practiced in sessions with the teacher and adapted to the client’s home practice at his/her discretion. Finally, as the existing literature on the topic reveals, yoga philosophy should be included as a tool to assist those suffering from RA to cope with the mental stress of unpredictable flares and chronic pain. The home practice element of yoga philosophy could include assigned reading of yogic texts, and journaling to keep track of symptoms and mental reactions to disease progression. Improvements in mental health symptoms are likely to be seen with increased self-awareness and self-regulation.

Predictably, my particular yoga for RA regimen harmonizes with current yoga therapy and CAM models in its holistic and patient-driven emphasis. Many previous developments in the fields of yoga therapy and rheumatologic medicine have contributed to the beginning success we now see in the research cited herein. The interdisciplinary collaboration of medical and yoga professionals in the treatment of RA patients, though already steadily progressing, merits increased attention and support from the wider medical and yoga communities.

REFERENCE LIST

Arthritis-Related Statistics. (2016, January 25). Retrieved March 14, 2016, from http://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm

Bernstein, S. (n.d.). Yoga Benefits for Arthritis. Retrieved March 14, 2016, from http://www.arthritis.org/living-with-arthritis/exercise/workouts/yoga/yoga-benefits.php

Evans, S., Moieni, M., Taub, R., Subramanian, S.K., Tsao, J.C.I., Sternlieb, B., & Zeltzer, L.K. (2010). Iyengar Yoga for Young Adults with Rheumatoid Arthritis: Results From a Mixed-Methods Pilot Study. Journal of Pain and Symptom Management, 39(5), 904-913.

Haaz, S., Bingham, C.O., Wissow, L., & Bartlett, S.J. (2015, July). Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial. The Journal of Rheumatology, 42(7), 1194-1202. doi: 10.3899/jrheum.141129. Epub 2015 Apr 1.

Haaz, S., & Bartlett, S.J. “Yoga for Arthritis: A Scoping Review.” Rheumatic Disease Clinics North America, 37.1 (2011): 33-46.

Rao, J. K. (1999). Use of Complementary Therapies for Arthritis among Patients of Rheumatologists. Annals of Internal Medicine, 131(6), 409. doi:10.7326/0003-4819-131-6-199909210-00003

Rheumatoid Arthritis Incidence on the Rise in Women. (n.d.). Retrieved March 31, 2016, from http://www.medscape.com/viewarticle/722944

Tabish, S. A. (2008, January). Complementary and Alternative Healthcare: Is it Evidence-based? International Journal of Health Sciences, (2)1, 5-9. Retrieved March 15, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068720/

Telles, S., & Singh, N. (2012). Is yoga a suitable treatment for rheumatoid arthritis: current   opinion. OAJSM, 81. doi:10.2147/oajsm.s25707