Yoga & Pilates For Neurorehabilitation: More Than Just .

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Yoga & Pilates forNeurorehabilitation: More thanJust ExercisePresenter: Yvonne van Bochove, PT, DPT, MA, CBIST, CPIContributor: Jennifer Schore, PTA, MS, MSW RYT

Objectives Gain an understanding of the history and evolution ofYoga and Pilates.Describe the principles of Yoga and Pilates and theirapplications.Understand the benefits of Yoga and Pilates specificallyin the rehabilitation setting.Enhance functional outcomes by utilizing Yoga andPilates principles for patients presenting with symptomssuch as, gait-, and/or balance disorders.Experience 2 Yoga and Pilates exercises withmodifications.

Yoga and Pilates techniques can address a wide range ofchallenges seen in the patient population with neuromuscular disease processes and diagnoses involving theneuro-muscular system, for example: Parkinson’s disease(PD), Stroke (CVA), Multiple Sclerosis (MS), TraumaticBrain Injury (TBI) and Acquired Brain Injury (ABI).

A Traumatic Brain Injury (TBI) is an injury to the braincaused by an external force after birth. Common causes of atraumatic brain injury include gunshot wounds, motorvehicle crashes, assaults, or falling and striking your head. An Acquired Brain Injury (ABI) includes all types of braininjuries for instance brain injuries caused after birth, bycerebral vascular accidents (commonly known as stroke),loss of oxygen to the brain (hypoxic brain injury) and braincancer.Source: 43913

Table 1Common Impairments Encountered in Rehabilitation for People with Post-Acute Neurologic DisordersSource: Martin and Kessler (2007); Johansson, Bjuhr and Ronnback (2012)TBI traumatic brain injury, CVA cardiovascular accident , PD Parkinson’s Disease, MS multiple sclerosisRespiration/ fatigueBalance/ coordinationMuscle weaknessRigidity/ xxxxxxxxxxxxxx


So what is yoga?

Yoga is a practice of breathing exercises and poses that aremeant to quiet the mind. Meditation is often an integral part of yoga practice. Iyengar himself said of yoga: “Practice and detachment are the means to still themovements of consciousness”

What does the research on yogaand meditation tell usabout their effectiveness?

Anecdotes and hype abound about the ability of yoga tonot only improve flexibility and strength, but also to addressproblems like difficulties with sleep, body weight, sexualsatisfaction, or will power. However, rigorous studies of yoga’s effects on the generalpopulation are few.

William Broad, a science writer for the New York Timesand a practicing yogi himself, conducted acomprehensive review of the research on yoga in 2012. He found claims of yoga as a path to physical fitness (thatis, physical strength and endurance) wereunsubstantiated by rigorous research.Broad, William (2012). The Science of Yoga: The Risks and Rewards. New York, NY, Simon and Schuster.

On the other hand, he also found good evidence thatyoga can improve mood through its ability to increaselevels of the neurotransmitter GABA. GABA (gamma-aminobutyric acid) promotesrelaxation and reduces anxiety; low levels of GABAare associated with depression.

And what is yoga’s effect on people with neurologicdisorders? Lynton et al. found very limited research on yoga’seffectiveness for people with a CVA. However, they did find some evidence that yoga improvedoutcomes related to CVA rehab, such as auditory and visualreaction time, strategic planning, and fine motorcoordination. Lynton, Holly, Benjamin Kliger, and Samuel Shiflett (2007).Yoga in Stroke Rehabilitation: A Systematic Review andResults of a Pilot Study. Stroke Rehabilitation, vol. 14, no.4, pp. 1-8.

Which Brings Us to Meditation

Meditation is “focusing one's mind for a period of time,in silence or with the aid of chanting, for religious orspiritual purposes or as a method of finition/meditate) Others would say it’s “a precise technique for resting themind and attaining a state of consciousness that is totallydifferent from the normal waking ew/the-real-meaning-of-meditation)

Mindfulness-Based Stress Reduction (MBSR) is aparticular type of meditation that has recently been thesubject of high-quality scientific research. MBSR is a highly structured 3-part program that includesmeditation, simple yoga poses, and body scanning.

MBSR was developed by Jon Kabat-Zinn in the 1970s. Kabat-Zinn trained as a molecular biologist at MIT, butalso studied meditation and Buddhism.

In the last few years, MBSR has received a lot ofattention in the media and has been subjected toresearch, some based on random assignment of studyparticipants. Moreover, some studies of MBSR effectiveness havefocused on people with neurologic disorders.

Johansson et al. found that MBSR reduced fatigue andincreased information processing speed for people withstroke or TBI. Johansson, B., H. Bjuhr, and L. Ronnback (2012). Mindfulness-Based Stress Reduction Improves Long-Term Mental Fatigueafter Stroke of Traumatic Brain Injury. Brain Injury, vol. 26, no. 13-14, pp. 1621-1628. Azulay et al. found that MBSR improved self-efficacy formanaging emotional and cognitive symptoms and forproblem-solving, and increased life satisfaction amongpeople with mild TBI and post-concussive symptoms.Azulay, Joanne, Colette Smart, Tasha Mott, and Keith Cicerone (2012). A Pilot Study Examining the Effect of MindfulnessBased Stress Reduction on Symptoms of Chronic Mild Traumatic Brain Injury/ Postconcussive Syndrome. Journal of HeadTrauma Rehabilitation, (accessed September 9, 2016).

Finally, Eyre et al. (2016) conducted a study on 29 olderadults who were concerned about their memories failingand who, when tested, had mild cognitive impairment. Half of the adults was randomly assigned to the 12-weekstudy intervention (an hour per week of yoga and 15minutes per day of meditation) or to a group whoreceived a brain training program for the same duration.

Following the intervention, both groups improved in theircognitive test scores. But those practicing yoga and meditation also were: Less likely to be depressed Had better visuo-spatial memory (important for balance) Had increased brain communication across areas related toattention control.Eyre, Harris, Bianca Acevedo, Hongyou Yang, et al. (2016). Changes in Neural Connectivity and Memory Following a Yoga Intervention for OlderAdults: A Pilot Study. Journal of Alzheimer’s Disease, vol. 52, pp. 673-684.Reynolds, Gretchen (2016). Yoga May be Good for the Brain. The New York Times. June 1, 2016.

So who wouldn’t like to try someyoga? The breathing exercise (or pranayama) is called alternatenostril breathing (or nadi shodhana ). The pose (or asana) is called cat-cow (or bidalasanamarjaryasana).

Inhale Retention Sit in a comfortable cross-legged position on the floor(hips elevated), or in a chair with feet flat on the floorabout hip-width distance apart Place hands in the lap

Sit with good posture Head facing forward Chin tucked in slightly Spine long Shoulder blades pulled down and back lightly Shoulders aligned over pelvis

Close the eyes, or soften the gaze on a nonmoving objectahead of you Breathe in for as long as is comfortable without strain Hold the breath for as long as comfortable without strain Exhale slowly

Notice how the breath feels in the body. Can you feelyour ribs expand and contract? Does the air on the inhalefeel cooler than the air on the exhale? Are there places inthe body where the breath feels “stuck?” Places where itmoves more freely?

Notice how your body feels. Do you feel the touch ofclothing on your skin? Are there parts of your body thatfeel uncomfortable sitting? Are there parts of your bodythat feel more at ease? Notice what you hear or smell. Notice what you see behind closed eyes, or in the line ofyour soft gaze.

Finally, notice what your mind is doing. But just notice. Don’t engage in commentary, orinvestigation, or judgment. If you notice you are engaging your mind in this way, or ifyou notice your mind is wandering (planning, ruminating,or complaining), simply return your attention to yourbreath and body, without scolding yourself.

Alternate Nostril Breathing Builds on this inhale-hold-exhale practice It adds a mudra (a hand gesture) that facilitates inhalingin one nostril and exhaling through the other, thenreversing

To start, use the right ring finger to close off the leftnostril on the inhale, use the thumb and ring finger toclose off both nostrils on the retention, and use thethumb to close off the right nostril on the exhale Then reverse by beginning with the right thumb closingoff the right nostril on an inhale and ending with thering finger closing off the left nostril on the exhale.

Practice the observation of the body and mind describedfor the inhale retention pranayama That’s one full cycle of nadi shodhana This practice is believed to oxygenate and balance theright and left sides of the body and brain, as well ascalming the nervous system

Practicing YogaBidalasana

This asana works the trunk (or core) muscles by movingthe spine through flexion, contracting the abdominals(cat), and extension, contracting the paraspinals on theback (cow). Place the person in this picture in a chair, and the samemovements can be made from a seated position, usingarm rests for leverage

Start in a neutral position of good posture On an inhale, sink into cow position (or if seated, drawthe shoulder blades together and back) and hold for afew seconds On an exhale, round up into cat (or if seated, round theshoulders forward and hollow out the belly) and hold fora few seconds

Bidalasana is believed to enhance the functions ofabdominal organs, and calm the mind by relievingtension and stress in the body.

In conclusion, while the effects of yoga on physical fitnesshave not been upheld by the most rigorous studies, thereis good evidence that yoga and meditation improve someaspects of emotional and cognitive function. Furthermore, if trained by an experienced yoga teacher,basic yoga poses are unlikely to have any negative effectsand can be practiced throughout the life span.

Benefits of Pilates exercises In the United states and Europe, Pilates has become a targetof interest as a useful exercise. Pilates exercises were developed as an exercise method torelax and strengthen the body. Most of the studies on Pilates training programs havefocused on orthopedic remedial exercise or balanceimprovement in patients with low back pain or the elderly. Few studies have investigated the effects of Pilates inpatients with neurological conditions.

Pilates The Pilates method, developed over a 60-year period, is asystem of therapeutic exercises designed to: Stretch , strengthen and balance the whole body with anemphasis on the breath, mind, alignment and coordinated,flowing e.aspx,M.Decker, September 12, 2013

Pilates based physical therapy is an approach to healing,grounded in the moving body using the therapeuticmovements and techniques of classical Pilates as well astraditional physical therapy ctice.aspx,M.Decker, September 12, 2013

Pilates has taken on many forms; Fitness Pilates Clinical Pilates Pilates himself indicated that his method was meant tomake us responsible and in control of our own bodiesand our health; Pilates individualized each program for each client.

Joseph Pilates Born in Dusseldorf, Germany in 1880; Sickly child; 1912 moved to England: boxer, circus performer, selfdefense trainer; WWI – enemy alien, interned with other Germans; Became a nurse and started training other internees inphysical fitness; 1926 emigrated to the U.S. biography.html

8 Principles cisionBreathingStamina

Control Pilates program is built around the concept of musclecontrol; No sloppy movements; No movement performed just for the sake of performingor “getting through” an exercise; Each exercise must be performed with the utmost controlto avoid injury and produce positive results.

Centering Powerhouse of the body are the abdominal, low backand gluteal musculature; Pilates exercises initiate from the powerhouse and flowoutward to the extremities; Physical energy is exerted from the center to coordinatethe movements.

Precision Every movement in the Pilates method has a purpose; Every instruction is vitally important to the success of thewhole; Concentrate on right movements each time whenexercising or it will be performed improperly.

Stabilizing role of the trunk and backmuscles The focus is on muscles which control the lumbar andlumbosacral joints, such as:– Multifidus– Transversus abdominus– Pelvic floor– Part of the internal oblique.

Transversus Abdominus Traditional performance tests like the sit-up providesindications of the strength and endurance of the entireabdominal muscle group but does not indicate the specificfunction of the transversus abdominus.

Multifidus muscle Consists of a number of fleshy and tendinous fasciculi,which fill up the groove on either side of the spinousprocesses of the vertebrae from sacrum to axis. Stabilizes vertebrae in local movements of the vertebralcolumn

Multifidus and Transversus Abdominus Both have primary roles that do not include theproduction of motion. Co-contraction stabilizes the spine.

Preparation Pilates Lying on back with knees bent:1. Breathing ( hands on lower part of rib cage);2. Articulation and release (tighten buttocks and lift);3. Hip release (let bent knee fall to the side);4. Leg slides (draw heel towards buttock, and extend).

Pilates Mat Exercises “Hundred” “Roll up”

Pilates exercise with modifications in intensity:– Bridging;– Bridging with leg lift.

Arm chair Pilates exercises1) Spine TwistSit near the front of your chair, spine and pelvis asneutral as you can, feet flat on the floor.Cross your arms in front of you. Breathe in. Breathe outas you rotate your upper body to one side, contractingyour abdominals. Breathe in to stay; breathe out toreturn to center. Repeat other side. Repeat 3 times oneach side.Repeat the exercise, this time placing your left hand onyour left shoulder and your right hand on your rightshoulder.M. Merrithew. The Journal on Active Aging July August 2005 armchairpilates.pdf?sfvrsn 0

2) Mermaid Sit near the front of your chair, spine and pelvis asneutral as you can, feet flat on the floor. Breathe in as you reach your right arm to the ceiling.Breathe out as you lean to the left. Breathe in to return;breathe out to lower arm. Repeat on the other side.Repeat sequence 3 times.M. Merrithew. The Journal on Active Aging July August 2005 armchairpilates.pdf?sfvrsn 0

Research Article 1 Research on The effects of Pilates training on flexibilityand body composition. An observational prospective study. 47 adult participants in a Pilates program of 1 hour aweek, for 2 months.Segal, N., Hein, J., Basford, J. (December, 2004). The effects of Pilates training on flexibility and body composition: an observational study.Archives of Physical Medicine and Rehabilitation. 85(12), 1977-1981.

No statistical changes in truncal lean body mass or selfassessment of health. Flexibility improved significantly. Less intense Pilates exercise regime compared to 10 PTsessions had the same results in improved flexibility.Segal, N., Hein, J., Basford, J. (December, 2004). The effects of Pilates training on flexibility and body composition: an observational study. Archives ofPhysical Medicine and Rehabilitation. 85(12), 1977-1981.

Research article 2 Systemic review to investigate the effect of Pilatesexercises on Balance and falls in older adults. Randomized and controlled clinical trials were searched. High-quality studies were lacking. 2 hours or more proved to be beneficial for improvingbalance. Limited data on the impact of Pilates exercise on falls.Barker, A.L., Bird, ML, et al. (2015). Effect of Pilates Exercise for Improving balance in older Adults; A systematic Review with MetaAnalysis. Archives of Physical Medicine and Rehabilitation, Volume 96, Issue4, 715-723.

Research article 3Study to analyze the effects of Pilates exercise on static anddynamic balance in chronic stroke patients. 8 weeks, 3 x a week, mat based Pilates exercises. Significant improvement of Static and Dynamic balance.Lim, H. S., Kim, Y. L., & Lee, S. M. (2016). The effects of Pilates exercise training on static and dynamic balance in chronic strokepatients: a randomized controlled trial. Journal of Physical Therapy Science, 28(6), 1819–1824.

Research article 4To evaluate effects of a Pilates intervention on balance andfunction in community-dwelling older (aged 60y) adults. Randomized crossover study design lasting 16 weeks. Participants were allocated to either 5 weeks of a groupPilates training intervention or 5 weeks of usual activity(control).

Static and dynamic balance measures and leg strengthwere recorded. Static and dynamic balance significantly improved duringthe study and from pre- to post-Pilates. Bird, ML., Hill, K.D., Fell, J.W. (2012). A randomized controlled study investigating static and dynamic balance in older adultsafter training with Pilates. Archives of Physical Medicine and Rehabilitation Jan;93(1):43-9. doi:10.1016/j.apmr.2011.08.005. Epub 2011 Oct 5.

Research article 5The purpose of this study was to investigate the effects of an8-week program of Pilates exercise on gait in chronichemiplegia patients. 3 x a week, 60 minutes of mat exercises. Conclusion: The 8-week program of Pilates exercise had apositive influence on improving the gait ability ofpoststroke patients in particular gait speed. Theintervention could be applied to post-stroke patients withvarious levels of physical disability by adjusting theintensity of exercise.Roh, S.Y., Gil, H.J., Yoon, S. .Effects of 8 weeks of mat-based Pilates exercise on gait in chronic stroke patients. Journal of Physical TherapyScience. 2016 Sep; 28(9): 2615–2619.Published online 2016 Sep 29. doi: 10.1589/jpts.28.2615

Conclusion Pilates can be used to improve activation of trunk musclesand enhance lumbar and pelvic stability. Trunk muscles are needed to activate the rhythmicmovement that is part of the execution of gait. Pilates can be used in physical therapy treatments toimprove trunk stability, posture, gait, and balance oftenaffected by stroke, TBI, MS, etc. Pilates exercises, one hour per session, one to three timesa week for eight weeks, seems effective More quality studies needed.

“Physical Fitness is the first requisite of happiness”- Joseph H. Pilates

References and ResourcesAzulay, Joanne, Colette Smart, Tasha Mott, and Keith Cicerone (2012). A Pilot Study Examining the Effect of Mindfulness-Based Stress Reduction on Symptoms of Chronic Mild Traumatic Brain Injury/ Postconcussive Syndrome.Journal of Head Trauma Rehabilitation, (accessed September 9, 2016).Broad, William (2012). The Science of Yoga: The Risks and Rewards. New York, NY, Simon and Schuster.Eyre, Harris, Bianca Acevedo, Hongyou Yang, et al. (2016). Changes in Neural Connectivity and Memory Following aYoga Intervention for Older Adults: A Pilot Study. Journal of Alzheimer

Benefits of Pilates exercises In the United states and Europe, Pilates has become a target of interest as a useful exercise. Pilates exercises were developed as an exercise method to relax and strengthen the body. Most of th

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