Editor's note: This text-based course is a transcript of the Yoga With People Who Have Neurological Conditions Podcast, presented by Arlene Schmid, PhD, OTR, and Dennis Cleary, MS, OTD, OTR/L.
- After this course, participants will be able to:
- List neurological conditions which may benefit from yoga from a trained occupational therapy practitioner.
- Recognize how yoga might improve outcomes for clients occupational therapy practitioners treat.
- Identify how an OTP might be trained to use yoga in practice.
Dennis: Hi, everyone, and thank you for being here. Welcome to the OccupationalTherapy.com podcast. I am happy to be joined today by Arlene, a Colorado State University faculty member. Arlene, could you introduce yourself and tell us a little about what brought you here today?
Arlene: Hello! As Dennis said, I am in my 10th year as a professor at Colorado State University in the occupational therapy department. Before this, I was a faculty and research scientist at Indiana University and worked in the VA. For almost 20 years, I have been researching the benefits of yoga for people with disabilities, as well as integrating yoga into occupational therapy.
Dennis: Wonderful. Could you tell us a little about how you got interested in yoga and incorporating that into your practice? Is it the chicken or the egg? What came first?
Arlene: That is a great question. I am from Buffalo, New York. There was not much yoga around there when I was growing up. However, yoga is 5,000 years old, and it is now a hot topic. I moved from Buffalo to Hawaii right after graduating from occupational therapy school, which had a much different vibe.
Dennis: Where did you work in Hawaii?
Arlene: I was on the island of Oahu and Honolulu the whole time. I started doing yoga and felt great in my own body. I had about five jobs in five years, as many new grads do as they are moving around. I started to see the benefits of yoga, regardless of the client. I worked in skilled nursing facilities, inpatient adolescent psychiatry, schools, and an outpatient hand clinic. I used yoga with all these different folks and saw excellent results. They also began to integrate yoga into their daily life. I looked at the evidence and found only one study on yoga for carpal tunnel syndrome. So, I made the hard choice to leave Hawaii and do a PhD
I attended the University of Florida for my PhD, as I wanted to research older adult exercise and exercise physiology as no one was talking about yoga. Many people told me not to talk about yoga as it would not go anywhere. In this program, I learned the skills I needed to research yoga. About 2005, I went to Indiana and the VA. They did not embrace yoga immediately, but clients became interested as they were sick of being on medications. There was an internal, patient-level movement that began. People returning from Afghanistan and Iraq said, "I do not want any more pills. I want to try yoga." I received a grant for yoga and stroke. The VA population was a little trickier as they were World War II and Vietnam veterans.
Dennis: And they are well known for their interest in yoga.
Arlene: Yes, I note your sarcasm. It was quite a challenge, as you can imagine. We saw many positive physical, emotional, and cognitive outcomes across multiple populations, which is exciting when you think about OT being holistic and treating the whole person. I believe yoga is a way to do that by connecting the mind and the body.
Dennis: Wonderful. There are many different types of yoga. Many pediatric OTs are using yoga with the students. Can you talk specifically about yoga with neurological conditions? You mentioned stroke, but what are other diagnoses that yoga might help?
Arlene: Sure. The one population I have not worked with much is pediatrics, but you are right that it is taking off. Individuals feel calmer, so a big push is to use it with kids. My research focused on stroke and brain injury. We gathered qualitative research from both studies asking questions like, "What could we change?" and "What could be better?" The reply we kept seeing was, "I wish I had this earlier in my disease or disability," because we saw folks with chronic stroke and brain injury 20-25 years post-insult. From there, we went into inpatient rehab at the VA and a local rehab hospital, which was fantastic.
My mantra was, "Yoga for everybody!" For research, they wanted to know who the control group was or who was not going to receive this treatment. I struggled a bit with this ethically. However, as an OT and yoga lover, yoga for everyone was great. We had folks with diagnoses of spinal cord injury, locked-in syndrome, acute stroke, acute brain injury, diabetic neuropathy, chronic pain, and Parkinson's disease on our treatment lists. We can see that integrating yoga into rehab for all those different populations helps calm people's nervous systems and help them function better in recovery. Think of all the tests like MRIs and therapy treatments they have to endure. Yoga gave people a tool to calm down, reduce their worry about the next thing, and help them to be more "in the moment."
We have not done a randomized control trial of yoga with these populations because it would be challenging to do. As such, it leaves us with a lot of questions.
Dennis: Gotcha. There are many different types of uses. We know each other reasonably well, and perhaps you have seen my lack of flexibility. Back when I was in occupational school many years ago, people would try to avoid being my lab partner due to my lack of range of motion. I am a novice to the idea when it comes to yoga. I know that different types of yoga are out there. Could you review some types of yoga and what might resonate with occupational therapy practitioners?
Arlene: There are many types. Mostly what is here in the West has derived from Hatha yoga, but they can all look different. For instance, if you Google yoga, you might get pictures of people standing on their heads or something. As you can imagine, we stay far away from having clients stand on their heads. While there are different styles, we mainly stick with Hatha yoga. All yoga should have a breath-to-movement component. In some yoga, every breath equals a new movement, and we want to stay away from that. Instead, we might have people focus on their breath in certain positions rather than moving in and out of postures. We have found that this makes the most sense for our folks. When you think of a chronic stroke population or someone with limited range of motion and mobility, they may have a fear of falling, so moving in and out of positions can be difficult. We try to get folks to the floor, and there can be anxiety doing that. We do this slowly and safely, incorporating fewer postures and more time for people to process the movement. We want every person to feel successful when they leave, so we provide a lot of hands-on assistance and modifications, which I think leans into occupational therapy. We are experts at modifying things and meeting people where they are, and yoga is naturally modifiable. I always worry that people picture the 20-year-old standing on their head, so I am trying to move us away from that and remind everyone that anyone can do yoga.
Anyone who can control their breath can do yoga. Some OTs do yoga in the ICU with people who have been trached and need to work on breath control. Remember, breath is yoga and does not have to be all of those postures. We are always thinking about safety throughout as well.
Dennis: Could you talk about some of the modifications you have used in your practice?
Arlene: Sure. First, everyone gets a yoga mat and yoga blocks, which are small foam blocks. We also incorporate blankets and bolsters so they can fold at the hips. We might do it while standing, but folks might want to do it while sitting, using a bolster to benefit from the forward fold without having to stand. The blocks have many purposes, like under someone's feet to help them feel more grounded. We often do this in schools to help ground the kids.
Dennis: Yoga or no yoga, the general rule is to get every kid's feet on the floor.
Arlene: It is essential for kids but the same for our older adults with neuro. We like to get them in standing if we can. We tend to start with chair yoga to get a sense of where everybody is. Usually, we stay in a chair for one or two sessions and then see how they do standing. We want to know their abilities and levels of fear. We start them in front of the chair and then move them behind it. They can use the back of the chair for support and then just a wall. And some of them graduate to being able to assume yoga postures, which is exciting for them and us to see. Everyday yoga uses blocks, belts, and bolsters, so it does not feel like they are using something because of their disability. I always use blocks and belts to get myself into the posture.
As mentioned earlier, getting to the floor is important. Many clients after a stroke have round bellies, so we only do things supine. It can be powerful for people to practice getting up and down from the floor and relaxing in supine postures. People love Shavasana, or corpse pose, in yoga. They lay supine and focus on their breathing. Many times people fall asleep as they are very comfortable. They look forward to this part, so we try to get them to the floor.
Dennis: I guess this is where our grading abilities come into play as occupational therapy practitioners. I knew an OT who was also a certified hand therapist that was opposed to using it with patients unless trained. She thought yoga had to be taken seriously before integrating yoga into practice. What are your thoughts about that? And if someone is interested, how would someone get training in yoga to start incorporating it into practice?
Arlene: That is a great and timely question. If you are an OT student at Colorado State, you get a lot of it from me as I integrate it into my coursework. We talk a lot about breathwork, so I feel comfortable telling an OT it is okay to work on breathing with clients. Like anything, you need to know why you are doing it. We can make people more awake, more sleepy, or stand up straighter through breath. We can all say, "I need you to take a deep breath and slow down to calm down your nervous system." We know this works because the vagus nerve runs through the diaphragm. When we take a deep breath, we engage the parasympathetic nervous system and calm ourselves down. I think we can remember that and take a moment with our client or ourselves and do that.
We need more training when we get into more specific postures or breathwork. It is acceptable for someone to say, "Let's do a warrior one or a lunge," as it opens up their hip flexors. At this point, is it yoga or a lunge? I think there is a fine line. If we are using it for someone who enjoys yoga, and it is their occupation, then absolutely we would do so. The other area is taking bits and pieces of yoga and integrating them into our practice for the best results. Lastly, a whole different group only uses yoga in their clinical practice. These folks are likelier to be like yoga therapists and only use yogic practices. I think it depends on what you want to do, and if you find yourself integrating yoga, then get more education to understand the philosophical underpinnings of yoga. It will help you to be a better therapist.
Before you walk into a patient's room, you should breathe and be in the moment. We know that breath helps people be more aware, and I think our therapists and clients are better when they are not fretting about other things. So, I am not opposed to people doing yoga if they are not fully trained as yoga teachers. We must determine if it is a modality, an occupation, or somewhere in the middle for folks.
Dennis: Right! We hired an occupational therapy student who did some work with my mother, who passed away a few years ago. She would go and hang out with her, but one of the things she started to do was some breathing techniques. It helped my mom with her anxiety. At her funeral, the student everyone through the Buzzy Bee Breathing. It was amazing to see the difference in the room after she did that.
Arlene: I love that! The energy that comes from a group is truly different from one-on-one. There is no way to research that, but we feel it. In some ways, it is a way to connect with people.
Dennis: You talked about some of the conditions you felt were appropriate for yoga. You also indicated that the vast majority of the clients could benefit from breathing and the relaxation aspect of it. Can you talk about how you relate yoga to occupational performance? Do you see some improvement in occupational performance in your clients?
Arlene: I get super excited about this. One, I think yoga is great, but it is not enough. It is best when it is merged with occupational therapy. Most of our studies have been yoga only, but now we are shifting to yoga and OT. What we have found over and over is a dramatic change in the quality of life. Using the Canadian Occupational Performance Measure (COPM), we see significant changes and satisfaction with performance for many diagnoses like chronic pain, brain injury, and Parkinson's. Using this tool, we are looking at activities that are important but challenging to the client.
In yogic philosophy, the physical body changes first with yoga and then moves forward. When people feel better in their bodies with more range of motion and increased balance, it allows them to do more things they want. We also see a change in confidence. We started thinking it was balance confidence, and it turns out it is overall confidence. They feel like a different person, and they can do more things. This spirals quickly as most of our studies are only eight weeks, and we see these changes in occupational performance and satisfaction.
The other exciting thing is that while we tend to see a change in performance, the change in satisfaction is what is more significant. They acknowledge that they have changed and can do things better, but it also seems they have shifted their attitude. They are more satisfied as they are less worried or anxious. This is part of the trouble with yoga research. People tell us so many positive things, but we may not always have an outcome to go with it. People say, "You've changed my life," or "You've rocked my world." I love those quotes, but I cannot measure that.
Dennis: Those are thank-you notes for your dossier.
Arlene: They are the best. It is exciting to see those changes in occupation and other areas. And if we can do something twice a week for eight weeks and see that much difference, that is exciting.
Dennis: When specifically thinking about neurological injury, does the evidence show that yoga is beneficial? We talked about some qualitative changes, but are there any physiological changes you can measure?
Arlene: There are things that we do measure. In yogic philosophy, if we are not living a healthy lifestyle, we may have some cognitive or emotional impairment. We may be forgetful or tearful. There are also physical changes. By adding yoga, we see physical improvement first, and then emotional and cognitive changes come next. Those folks post-stroke 20 years ago may show measurable changes in balance, strength, and range of motion. For instance, we have done studies with NeuroCom, which provides a computerized measure of balance. You can see structurally that they are putting both feet down more equally and things like that. I typically see a change in posture at about week two or three. They are sitting up straighter and breathing better. Then, we start hearing about other positive changes like emotional regulation. They may say, "I do not cry at every Hallmark commercial anymore."
Dennis: What if we want to cry at the Hallmark commercials?
Arlene: I know. They are the best.
Arlene: They may also say, "My wife just told me she feels like she got her husband back." Again, this is not something I can measure, but I hear it repeatedly. We hear great stories like, "I can walk up the stairs for the first time since my stroke." This is great, but the point is that they can now sleep in bed with their husband or wife for the first time since their stroke. There was a shift in emotion and emotional attachment because of the stroke and those physical changes. Physical outcomes are easier to measure and happen faster.
We do not know whether eight weeks is the correct dose of yoga. We picked eight weeks because most exercise science says that six weeks are when you see changes. We wanted to align our model on this because we did not know where to start otherwise. What people are now trying to figure out is whether this is the proper timing for not only yoga but also occupational therapy. At this point, we have no idea.
Dennis: I say twenty minutes a week for life. I am just kidding.
Arlene: I say forever because we all need it. Does it need to be twice a week forever? Probably not, but there is some current research to figure out when people start to feel the change in therapy, particularly in brain injury. One dose of yoga helps people feel way better, which is exciting, but there are still a ton of questions to be answered. I am excited about physical improvements, but I get excited when people say, "I feel like myself for the first time," or "I am getting back to XYZ, which is important to me." They feel like they are living their lives again.
Dennis: It is like that snowball rolling and getting bigger and bigger. Once they start to improve physically, then emotionally, they feel better. What makes it challenging as a researcher is to figure out what is what.
Arlene: It does, but it is exciting all the same. I love being in the clinic and being an OT, so it was hard to leave. I left to do this, and 20 years later, it is still what I am doing. I feel like I made the right choice and am adding to the literature.
Dennis: Although you are not in Hawaii, Colorado is still pretty cool.
Arlene: Yeah, Colorado is pretty awesome. We get back to Hawaii pretty often, which is also lovely.
Dennis: You have mentioned pain. With your early work in the VA, I would think pain is a big issue, especially for those dependent on medications. Can you talk about pain and yoga specifically?
Arlene: We have seen excellent results and significant changes in the COPM. We have noticed an interesting mix of people who want to keep progressing and come off their meds. We ran a yoga pain study in a local pain clinic, and they were so happy with the results. They had the yoga teacher, an OT, continue with the program. I also had a student go back and run the program to they ran this program for two and a half years. We interviewed ten people and used the COPM. The changes were outstanding, with one woman saying, "Before I was only existing, and now I am living."
There is another group that identifies with their pain. When you first meet, they may say, "I have had pain for 20 years." Pain has become part of their identity. These people tended to drop out because their identity was wrapped up with their chronic pain. We were also not offering how they could return to regular occupations after 10 or 20 years. We even had a couple of people who needed fewer drugs, opioids precisely, and were afraid that their doctor would take their opioids away. They dropped out because their pain was much better, and they needed the drugs because they were addicted. Those were interesting issues that we did not expect to see.
For most of the folks, their pain did not go completely away. We used the Brief Pain Inventory, which has a total score for pain severity and then the interference of pain in everyday life. While the pain severity did not change, the interference of pain in daily life significantly improved. People said, "The pain did not go away, but I could put it somewhere else," or, "I could think about other things and engage again."
Of all the studies I have done, this is probably the most challenging population, as pain is diverse. Again, I may not be a good researcher as I believe yoga is for everybody. For example, if people had migraines, they could be in the same study as folks with low back pain or internal radiation burns after cancer. All of these types of pain are so different. They are all pain, but the pathways are different.
Dennis: We needed to train you as a researcher before OT.
Arlene: I know! It is hard.
Dennis: Exactly. Let's help people.
Arlene: Yeah, and I can still tell a good story about it at the end of the day.
Dennis: Absolutely. Is there evidence that yoga is different from a typical exercise program?
Arlene: Yeah, there is. About 20 years ago, some basic studies about yoga versus exercise were completed. These studies showed more improvement in those doing yoga versus weight training exercises. What we tend to do for control groups is to match yoga to another activity with the same metabolic expenditures (METs). However, these were exercises in a single plane of movement and with healthy adults.
Our group thought, "What about people with stroke and brain injury?" We have not tested yoga against regular exercise, but we have used a control group that did not do breath with movement.
Dennis: Society is probably so different from when those studies were completed. Regarding studies, how do insurance companies view yoga as part of occupational therapy? Is it simply a modality we are using?
Arlene: The answer probably falls somewhere in the middle. This is a "depends" answer. For example, a mental health setting may be likelier to be cool with it. We studied this and spoke with therapists across the country who integrated yoga into practice. Their takeaway was that insurance would not pay for yoga but would pay for an occupational therapist using a therapeutic activity (yoga). They were thoughtful about how they wrote things, which may not include the word yoga. I think it depended on the population they were treating and to whom they were writing. For example, we have worked with folks in the burn ICU, and yoga makes excellent sense in this setting. It calms the nervous system and helps them stretch out. With yoga, you can cool or heat your body with your breath. Therapists have been able to finesse their notes to insurance companies.
One of my goals in life is to provide evidence for yoga. My colleague, Dr. Jacqueline Stevens, has a funded study figuring out why yoga works. It is harder to sell to the insurance company if we do not know what is changing. Overall, I am just happy that people are so glad. In this study, we are completing brain imaging with those with a brain injury. We are using fMRI (Functional magnetic resonance imaging) and something else called fNIR (Functional near-infrared spectroscopy), which is exciting. In Dr. Steven's study, they wear a cap with electrodes while doing yoga postures so that we can view brain changes. She sends me pictures of people's brains, and I can see they look different. This is why we collaborate; she has the imaging, and I bring the yoga.
Also, after only eight weeks, there is some excellent evidence on mindfulness. Yoga includes mindfulness and meditation. In healthy adults, we can increase gray matter and connectivity in the brain with meditation, so that is where we were trying to get to with the yoga research. What part of the brain changes after an injury, and what are we actively working on to fix this? Some other folks are now starting to try to add to that literature.
Can someone with a stroke safely do yoga? We are way past that now and can say that yoga is safe and beneficial. We are trying to figure out the "why" and the things changing in the body.
Dennis: There are undoubtedly several OTs providing some of these interventions on a cash basis. However, if we can have yoga as part of our typical evaluation and treatment, that will be terrific. Thanks for doing that on behalf of the profession.
Arlene: Thanks, I love it.
Dennis: Can you talk a little bit about precautions?
Arlene: Physical safety is of utmost importance, and we are constantly working to prevent falls. We have not had any incidents, so knock on wood. We have been very safe, but even something like a forward fold in a chair can make someone feel dizzy or nauseous. We talk to people about that and tell them to listen to their bodies. Often, people become disconnected from their bodies, especially after some of these injuries. We work with them to listen to their body. If they feel dizzy, they need to sit back down.
Again, getting to the floor is vital for yoga, but we must do it safely. Yoga can bring up some stuff we have not thought about for a while or packed away. Sometimes people become emotional or tearful during yoga. We want to make sure we are checking in with folks. This does not happen every session, but it has happened. For example, we tend to hold a lot of stress and anxiety in our hips. So when we open the hips or move people into an extended posture, we risk getting some emotion. Be prepared for this and use your mental health background to treat the whole person.
In acute care, particularly acute brain injury and stroke, we should not do any inversion like a headstand or down dog. We should probably wait a year to do inversions with someone with a brain injury or stroke. We do not want to cause more damage. It is not necessarily that we have research on this, but we do not know enough.
Dennis: What would occupational therapy personnel bring to yoga that a yoga teacher may not?
Arlene: I love working with OTs who are yoga teachers because they understand anatomy and physiology, and their training is more advanced. They also appreciate precautions. An easy example is hip precautions. A yoga teacher probably has never heard of that before. An OT will know how important it is to follow those protocols. OTs are also more likely to say, "We're going to take this step by step and get this person where I need them to go." I think an OT also can manage mental health issues.
We have adapted yoga at the community level in Colorado, and I am not sure other communities are doing this yet. Before the pandemic, these classes were in person, specific for Parkinson's, MS, and other things. It was not OT doing it. People realized a population would benefit from yoga and started a program. After COVID, this has moved online. I think most folks would struggle to go somewhere and take a class. There may be a senior center that offers senior yoga, which is probably the best bet.
Dennis: In terms of providing individual and group interventions, can you talk about the difference between those two when you are using yoga as part of your practice?
Arlene: We have only done individual a handful of times with those with a brain injury and in an inpatient rehab setting. I think one-on-one treatment can be excellent because you can connect with the client and meet their individual needs. If their hip hurts, you can address this through yoga. We mostly do group yoga because many like group intervention. There is also better attendance which may or may not be about the yoga but may be due to the social aspect. Group yoga is a little harder to study because we have to standardize it, so everyone gets the same yoga. As OTs and yogis, we want to meet people where they are. We say it is a standardized intervention, but we tailor it to their individual needs. For example, if they need an extra yoga block, we consider that they still did the pose with some additional modifications.
One-on-one and group treatments have different benefits. We can target things differently in that one-on-one, but we have better outcomes with the group, or at least that is what we have seen.
Dennis: Can you talk about some clients who have benefited from yoga? Do you have a favorite story? You have already talked about a couple, but do you have particular clients that have benefited from yoga?
Arlene: I had two clients that both had aphasia, with one gentleman who had his stroke 22 years before. He had a stroke in his forties, which dramatically changed his life. He had to stop working, and his kids were still little. It was very traumatic for him. All he could say was, "Yep," but he could understand and follow directions. He came to yoga with his wife, as we include caregivers if they are interested. At about week three or four, during yoga, he said, "Arlene, shut off the lights."
Arlene: Everyone thought, "Wow, you talked!" He knew my name and what was happening. This was week three of yoga intervention, 22 years after his stroke. I think we will never understand why that happened. I think it is about being in the present moment. He was stuck in the past of thinking, "Why did this happen?" I think yoga helped him be more okay with where he was.
Another client with aphasia was also doing yoga with his wife. This allows the caregiver to get the benefits of yoga and not worry about their spouse during this time. They were at home, and she was helping him with a shower. He took the shower head and squirted her with water, and laughed. He thought it was the funniest thing. She said, "It was the first time I felt like we were a couple, and I was not a caregiver." They had a shared occupation of going to yoga together, which was powerful for them as a couple. We often lose many of these occupations after a stroke or taking on a caregiving role. I have so many folks in my head after almost 20 years, but these two stick out.
One other person is a lovely woman that I treated. I wrote a book on yoga and stroke, and she is the model for it. She loved yoga and could feel parts of her body again for the first time. She tells anybody who wants to hear about how great yoga is. She could do all of the postures and was the perfect model of how you can adapt yoga for someone. She has quite a lot of hemiparesis in her leg and her arm but was able to do everything after modification. There are so many great people I have worked with over the years.
Dennis: You are doing an intervention that is an occupation that they can take with them.
Arlene: We hear that they do yoga. They are doing the things that feel good.
Dennis: You mentioned your book. Can you tell us more about that and give some advice for occupational therapy practitioners that are now intrigued after this talk?
Arlene: Writing a book is a lot of work, but I am happy with it. There is a whole chapter on stroke and another on yoga. It can serve as a foundation for people and show some of the physiology behind what is happening. Yoga makes sense when we think of the parasympathetic nervous system. It uses the model mentioned above and shows how to modify all poses. It is a practical book with handouts. My primary collaborator was Marieke Van Puymbroek, a rec therapist at Clemson University. We do a lot of our work together.
Dennis: Where do you access this?
Arlene: It is called "Yoga Therapy for Stroke." I have been talking and doing yoga for 25 years. It ebbs and flows for me, and there are times when I have given it up when I have gotten busy. We can follow a ton of yoga online, and even more with COVID. Doing five or 10 minutes daily is better than one hour a week. I think including some breath work is also powerful, as we can calm down our nervous system and be more aware. I talk to my students a lot about that. I think yoga can help most of us be better therapists at the end of the day, regardless of if you are teaching it to your clients or not.
Dennis: Clients often do not remember what we did with them, but they remember how we made them feel.
Arlene: It is so true. I think we are better therapists if we are truly with our clients and not worrying about getting our notes done or whatever else is on our minds. My philosophy is that yoga is for everyone, regardless of disability, population, or where you live.
Dennis: Well, Arlene Schmid from Colorado State University, thanks for a great discussion.
Arlene: Thanks, you too.
Available in the handout.
Schmid, A., & Cleary, D. (2022). Yoga with people who have neurological conditions podcast. OccupationalTherapy.com, Article 5542. Available at www.occupationaltherapy.com