Medical Yoga at UVA by Ina Stephens, MD

Mental health issues are epidemic among today’s youth.  Recent studies suggest that up to half of all teens have complaints related to stress, anxiety, and/or depression.  In the United States, we have an unprecedented rise in the rates of child and teen suicide. The American Academy of Pediatrics is now recommending universal depression screening for all teens, a recommendation that promises to recognize patients at risk of severe mental health disorders, but also to increase the demand for mental health services among your patients and their families.  In addition to patients presenting with primary mental health disorders, many patients with acute or chronic illness have difficulty adapting to their diagnoses or disabilities.  Mental health services are needed to assure that such patients are able to achieve the best health possible.

Medications are available to ameliorate mental health disorders, and many can be safely used in the primary care setting; individuals with more severe disorders may require referral to competent mental health professionals.  However, many of these medications have unwanted side effects or are not familiar to the primary care physician, and mental health professionals are scarce in parts of Virginia.  For these reasons and others, primary care physicians require additional approaches to respond to the challenges imposed by a growing number of patients requiring mental health support.

Mindfulness practices have ancient origins in many cultures.  Such practices share the essential effort of directing awareness to the present moment.  Mindfulness practices, in a sense, allow one to witness, or observe, their thoughts and emotions, rather than immediately reacting or getting caught up in them.  The practices help one understand that the individual is not simply his or her thoughts or emotions, thus empowering the patient to control negative ideation, or accepting such thoughts with grace and detachment. When undertaken regularly, mindfulness practices have been shown to confer an extraordinary number of health benefits.  Mindfulness practitioners report reduced anxiety and depressive symptoms, improved cardiovascular health, better sleep, and better ability to adapt to social and personal challenges.  An increasing number of studies have shown that yogic practices, such as mindfulness meditation, can help ease stress, depression and anxiety, and in fact, may be just as effective in treating symptoms as antidepressants (1).

Western society has not traditionally embraced mindfulness practices, a fact which may contribute to the growing mental health epidemic.  However, there is a growing movement to introduce simple methods of present moment awareness, techniques which can be incorporated into the daily life of even young patients.  The most common practices include meditation and contemplation, mindful breathing, mindful walking (or eating, or in fact any action), deep breathing techniques and yoga asanas (postures and mindful movement).  Meditation is difficult for most western pediatric patients, who are more used to an environment of near-constant stimulation, but active mindfulness can be taught and embraced by nearly any child of school-age and beyond.  It should be noted that Yoga is not a religion, but can deepen and benefit anyone in any religion.  Yogic practices do not conflict with personal beliefs.  Yoga is simply a tool that can transform oneself and promote conscious connection with oneself and the world.

Yoga is a particularly powerful mindfulness practice for promoting teen mental health (2). This ancient practice is markedly effective in improving health and well-being, provides stress relief and emotional regulation, and helps teens learn self-care. Self-care and learning to self-regulate are vital tools against mental illness and substance abuse, promoting a healthy body and mind (3). Recent research has shown that yogic and mindfulness-based practices can positively impact the body in many ways, including helping to regulate blood glucose levels and keeping the cardiovascular system healthy.  They have also been shown to have important psychological benefits, as the practice of yoga can help to increase alertness and positive feelings, and decrease negative feelings of aggressiveness, depression and anxiety (4–9).

Physiologically, mindfulness practices like yoga and meditation work by modulating the body’s stress response systems (10).  They can help to calm the nervous system by enhancing parasympathetic tone and bringing the autonomic nervous system into balance.  These practices decrease physiological arousal by reducing heart rate, lowering blood pressure, easing respiration and increased heart rate variability.  Yogic practices have been shown to increase the body’s levels of natural “happy neurotransmitters” such as GABA, serotonin, melatonin and oxytocin (11).  The practices can calm the limbic system and enhance the work of the prefrontal cortex, helping to regulate impulse control including how one reacts to stress, regulates emotions, enhances executive function and decision making.  Yoga decreases the size of the amygdala, which is the brain’s “threat” center – responsible for fear, anxiety and stress (12-15). The body goes through several physiological changes in response to stress – in fact >1400 biochemical reactions occur in response to stress, which subsequently results in alteration of our autonomic nervous system.  If continued, these responses can cause significant perturbations, including inflammation and chronic illness.  Signs of stress include  apathy, lack of energy, difficulty making decisions,  difficulty “keeping track” of things, feeling on edge,  change in eating habits, sleeping more than usual or difficulty getting to sleep, insomnia, being more emotional, and substance abuse. Of note, symptoms of stress include mental illness and many other chronic illnesses, including chronic back pain, tension headaches, migraine headaches, neck pain, gastrointestinal problems (pain, diarrhea, IBS), palpitations, depression, anxiety, cognitive inhibition, impaired memory and weight gain.

Of particular importance as well is the fact that many typical habits of today’s teens include enormous tech consumption, screen time, social media and less time spent in nature and outdoors.  This prevents them from “truly being with themselves” and can lead to a feeling of disconnection from themselves and others. Yogic practices are about learning to pay attention – to one’s self, one’s body and to others. This can lead to a deeper awareness of one’s internal state, and can help heal this disconnect.   In addition, yogic breathing can calm the nervous system very quickly, and studies have shown that teens can use them effectively to relax before exams, help them sleep, and calm them down when they are angry. When done regularly, focused and controlled breathing can help to control one’s changing emotional state and stress level, allowing the mind and body to relax and move towards healing, resilience, connectedness and wholeness.

Yoga practice improves physical fitness and strengthens the respiratory system, making one feel stronger and more in control of one’s body.  It is not surprising that yoga is rapidly growing across America.  Yoga studios are now found in most towns and cities, and yoga teachers can be found in studios, on the internet and on television.  In addition to active mindfulness, yoga can also serve as a safe and effective exercise for nearly anyone, and a way to manage the many disorders caused by tightness of joints and muscles.  In fact, in February of 2017, the Annals of Internal Medicine revised its clinical guidelines for chronic lower back pain to include yoga, mindfulness-based stress reduction and other non-pharmacologic treatments as front-line therapy for chronic lower back pain (16).  The availability of yoga to Americans will lead to the long-term integration of this practice into the lives of many individuals, with lasting benefit.

Although yoga is available to nearly anyone, there are individuals for whom yoga offers both special opportunities and special challenges.  Patients with physical, or even mental, disabilities, for example, may not be well-served in the average commercial yoga studio.  Conventional yoga teacher training does not prepare the teacher to deal with special patients, nor to maximize the effects of yoga for medical diagnoses.  Thus has been born the specialty of Yoga Medicine, which offers the safest and most effective way to serve the patient with physical or mental disabilities.

UVA is among the first institutions in the US to offer a formal Medical Yoga Clinic, and one of the very few to offer this specifically for pediatric patients.  In the Medical Yoga Clinic, physicians with special yoga certification prescribe and lead practices that can improve a wide range of disorders, in ways that are safe and non-invasive.  Once taught, patients can perform the practices on their own, with follow-up as required by the clinic.

Among the more tractable disorders for the Medical Yoga Clinic include anxiety, mild depression, chronic pain, musculoskeletal complaints, asthma, ADHD and high-functioning autism. Medical Yoga intervention may be integrated with any current therapy or medical regimen. Yoga practices with particular focus on mindfulness offer a safe and effective intervention for a growing number of pediatric patients.  For a thorough review of Medical Yoga Therapy, see the following article (17).

Referrals to the Medical Yoga Clinic at UVA can be made by calling 434-924-5321.

 

Ref:

  1. Goyal M, Singh S, Sibinga EM, etal. Meditation Programs for Psychological Stress and Well-Being: A Systematic Review and Meta-analysis. JAMA Intern Med. 2014;174(3):357-368.
  2. Noggle JJ, Steiner NJ, Minami T, etal. Benefits of yoga for psychosocial well-being in a US high school curriculum: a preliminary randomized controlled trial. J Dev Behav Pediatr. 2012 Apr;33(3):193-201.
  3. Gard T, Noggle JJ, Park CL, etal. Potential self-regulatory mechanisms of yoga for psychological health. Front Hum Neurosci. 2014 Sep 30;8:770.
  4. Miller, J.J.; Fletcher, K.; Kabat-Zinn, J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen. Hosp. Psychiatry 1995, 17, 192–200.
  5. Yadav, R.K.; Sarvottam, K.; Magan, D.; Yadav, R. A two-year follow-up case of chronic fatigue syndrome: substantial improvement in personality following a yoga-based lifestyle intervention. Altern. Complement. Med. 2015, 21, 246–249.
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  9. Danhauer, S.C.; Addington, E.L.; Sohl, S.J.; Chaoul, A.; Cohen, L. Review of yoga therapy during cancer treatment. Support Care Cancer. 2017, doi: 10.1007/s00520-016-3556-9.
  10. Goyal M, Singh S, Sibinga EM, etal. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014 Mar;174(3):357-68.
  11. Streeter CC, Gerbarg PL, Saper RB, etal. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. 2012 May;78(5):571-9.
  12. Carrion, V.G.; Wong, S.S. Can Traumatic Stress Alter the Brain? Understanding the Implications of Early Trauma on Brain Development and Learning. J. Adolesc. Health 2012, 51, S23–S28.
  13. Carrion, V.G.; Weems, C.F.; Richert, K.; Hoffman, B.C.; Reiss, A.L. Decreased prefrontal cortical volume associated with increased bedtime cortisol in traumatized youth. Biol. Psychiatry 2010, 68, 491–493.
  14. Travis, S.G.; Coupland, N.J.; Hegadoren, K.; Silverstone, P.H.; Huang, Y.; Carter, R.; Fujiwara, E.; Seres, P.; Malykhin, N.V. Effects of cortisol on hippocampal subfields volumes and memory performance in healthy control subjects and patients with major depressive disorder. J. Affect. Disord. 2016, 201, 34–41.
  15. Holzel, B.K.; Carmody, J.; Evans, K.C.; Hoge, E.A.; Dusek, J.A.; Morgan, L.; Pitman, R.K.; Lazar, S.W. Stress Reduction correlates with structural changes in the amygdala. SCAN 2010, 5, 11–17.
  16. Hochberg, M.C.; Altman, R.D.; April, K.T.; Benkhalt, M.; Guyatt, G.; McGowan, J.; Towheed, T.; Welch, V.; Wells, G.; Tugwell, P. American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res. 2012, 64, 465–474.
  17. Stephens, I. Medical Yoga Therapy. Children, 2017, 4, 12; doi:10,3390/children4020012.