Friday Q A Vaginal Prolapse

Q: I have a vaginal prolapse and my surgery in 3 months time will possibly include a vaginal hysterectomy. I am 75 and an Iyengar teacher. Please could the team cover this procedure some time? I would welcome your comments on how to prepare for surgery and how to modify my practice post operatively for a better recovery.  

A: A few weeks back, I addressed a question about pain following a partial hysterectomy (see Friday Q&A: After a Partial Hysterectomy), and briefly described what a partial hysterectomy is:

 “A partial hysterectomy refers to a procedure where only the uterus is removed, not the cervix or the ovaries. This type of operation involves a shorter recovery time, and is commonly used in the treatment of fibroids and severe and uncontrollable vaginal bleeding.”  

I also mentioned that mesh is used to hold the cervix and vagina in place to prevent them from prolapsing or bulging outside the vaginal opening. With our question today, a vaginal hysterectomy is being recommended because there is already a prolapse of the vaginal structures out of the body.

Before we discuss the procedure to fix this, it is worth understanding what “vaginal prolapse” means in greater detail, what causes it, and why it is important to fix. According to the Cleveland Clinic:

In vaginal prolapse the vagina stretches or expands to protrude on other organs and structures. The situation seldom involves the vagina alone. Supports for the uterus often stretch allowing it to also fall (prolapse) when a woman strains during a bowel movement.

• When the protrusion involves the front (anterior) of the vagina and bladder, the presentation is called a “cystocele” or dropped bladder
• When the back (posterior) of the vagina and rectum are involved, the presentation is called are “rectocele”
• When the anterior vaginal wall and small bowel are involved the situation is called an “enterocele”

And these combinations of structures bulge down and out of the pelvic floor and vaginal opening. Although many women don’t have any symptoms, some will notice a fullness or discomfort in the vagina, a heaviness or pulling in the pelvis, or low back pain that gets better when lying down. Sometimes the prolapse affects normal bladder function, resulting in frequent urination or stress incontinence (loss of control of bladder with coughing, sneezing, laughing, or strongly engaging the belly muscles). When the rectal area is involved bowel movements can be difficult. And the prolapse can interfere with intercourse, which can also become painful. 

As for causes and risk factors, the number one risk factor for developing prolapse of the vagina is having a history of vaginal childbirth, especially more than one time, and aging. Menopause can also negatively affect the tone of the muscles of the pelvis floor. Aging can lead to a weakening of the muscles in general, so the pelvic floor can be affected, too. Chronic cough and chronic constipation can also be risk factors.

If symptoms from the prolapse are significant for a woman, non-surgical treatments are usually tried first, such as teaching the patient pelvic floor muscle strengthening exercises, and possibly the use of a small device placed in the vagina called a pessary, which helps keep everything up and out of the vaginal opening. But for whatever combinations of circumstances, our reader is scheduled for a vaginal hysterectomy. This is a surgical procedure that removes the uterus, possibly the cervix, and, also in post-menopausal women, the ovaries (all are usually removed due to the risk of cancers developing in them over time if left in place). For the procedure, the surgeon enters from the vagina, so there is no cutting through the lower abdominal wall to get the structures and no scarring. The top of the vaginal cavity will likely still be tacked up to other parts of the inner walls of the abdomen to keep the vagina from prolapsing out after surgery.

In preparation for surgery it would be helpful to discuss with your doctor and physical therapist the pelvic floor exercises they recommend for those not undergoing surgery. There could be some nice overlap with some of the yoga poses and techniques that can strengthen the pelvic floor, such as Mula Bandha, and you could integrate your physical therapy techniques with your yoga poses to have your body in the best shape possible prior to surgery. Sometimes reclining can relieve back pain associated with vaginal prolapse, so Relaxation pose (Savasana) could be an excellent pose to do regularly if back pain is one of your symptoms. In addition, supported inverted poses where the pelvis is inverted, such as Chair Shoulderstand or Legs Up the Wall pose done with a prop under the pelvis, could be employed to use gravity to pull the vagina and uterus away from the pelvic floor, especially if they relieve symptoms, even if only temporarily. For more on pre-surgery recommendations from a trained physiotherapist specializing in pelvic floor, see Yoga Prolapse Poses to Choose and What to Avoid.

After surgery, you’ll want to follow the return-to-activity recommendations of your health care team, but restorative poses, pranayama practices that quiet the nervous system, and guided meditation with a focus on lowering stress could assist in faster recovery times. The good news is that compared to an abdominal approach hysterectomy that has a six-week recovery time on average, the vaginal hysterectomy recovery times are on average only two to four weeks. So it should not be too long before our reader is up and easing back into her normal activities, including practicing and teaching yoga again! 

For more non-yoga related advice on post-op recovery, see Recovery From a Vaginal Hysterectomy.

—Baxter

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Friday Q A Strengthening Your Quads

Extended Side Angle Pose

Q: My parents have started to suffer from osteoarthritis and have a transfer problem due to knee pain. I have started including some asanas to strengthen my quads. Do you think it is a good idea to use ankle weights to strengthen the quads?

A: As long as you have a relatively healthy body and joints, I think using something like ankle weights to strengthen the quads could be quite reasonable. Now, if you have significant knee or hip arthritis, you would obviously want to be guided by the amount of pain in the joints that the extra weight might cause. And if you were not particularly keen on using yet another extra item in your practice, rest assured that using your own body weight for resistance and strengthening can help to strengthen you quads, as well as longer hold with some of your standing poses. See Ram’s excellent post on Endurance Training for more information.

The ankle weights would be most likely to help build more quad strength when you take your leg into flexion a the hip joint, especially in poses like the standing pose Hasta Padangusthasana. In this pose, you start in Mountain pose and balance on one leg as you lift the other one up parallel with the floor or higher and use your same-side hand to hold that lifted foot (or use a strap if you are limited by tightness or leg/arm length challenges).

Another pose in which you could use the ankle weights is Reclining Leg Lifts, which in the yoga practice is called Urdhva Prasarita Padasana. I do these starting in Savasana, inhaling the arms overhead, then while exhaling the arms back to my sides simultaneously swinging one or both legs up to vertical. On my next inhale, I simultaneously lower the leg/legs back to the floor and take the arms back overhead, and finish by exhaling the arms to my sides. This can be repeated for a set of six or more. The ankle weights will make it a bit more challenging, and could potentially result in more muscle building in the quads.

Other postures that you could do that would not necessarily require or benefit from the ankle weights but would work to strengthen the quadraceps muscles in whole or part (since one of the four muscles that make up the quads flexes the hip joint, but all four extend the knee to straight), would include all of the straight leg standing poses done with attention to creating an isometric contraction of the muscles while in the held pose for a while. I usually shoot for about 90 seconds when working on muscle building and strengthening. You can actually check to see if you are engaging the muscles group by touching the front mid quad with your fingers to verify the muscle is firm and working. The straight leg poses poses I am referring to include Mountain, Triangle, Pyramid (Parsvottanasana), Half Moon pose (Arda Chandrasana), and Warrior 3 to name the most common.

You can get a slightly different effect of strengthening the quads by doing the standing poses where one or both knees are bent and once again working towards longer holds (gradually, of course, if you are starting out from a weaker places) of 90 seconds or so. My favorites are Powerful pose (Utkatasana), Warrior 1 and 2 and Extended Side Angle pose. 

I also like to do a wall version of Powerful pose, with my back to the wall, feet about two feet from wall and a block in between the legs near the knee joint so the part of the quads towards the inside of the leg, the vastus medialis, will get stimulated to contract due to the block squeeze. (This part of the quads is notoriously weak in many people, even regular yoga practitioners and can cause kneecap-tracking problems that can lead to arthritis in some.) You then slide your torso and hips down the wall until your thighs are no lower than parallel with the floor, and your knees are positioned over your ankle joints, and you hold the pose for a bit. This pose is often more challenging to weaker quads, so start off holding for a few breaths and very gradually over the course of weeks or months, extend the time in the pose.

So, with and/or without ankle weights, you can definitely improve quad strength with your yoga practice!

—Baxter

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Friday Q A Collapsed Lung

Front View of Heart and Lungs

Q: Got a friend (a smoker) who ended a camping trip in the mountains (probably around 6K feet) by getting a collapsed lung. His wife got him to the hospital and all is well--he is even back to enjoying his electronic cigarettes (says it is not really smoking!) Anyway, I was thinking of using this as an opportunity to (finally) get him to try breathing meditation, Yoga/Tai Chi—but the lung thing has me worried. This was spontaneous with no obvious indications of why it happened or if it will happen again. He does nothing half-way, this guy, so if I get him doing deep-breathing exercises he will be going for the max. Is there a danger of the collapse happening again or can we use deep breathing to strengthen his lungs?

A: Thanks for writing to us about your friend’s condition. As always, the information I will share is of a general nature and in no way a prescription for how you will want to work with your friend. But I hope the following discussion will give you more information to work with as you try to help your buddy. 

Let’s start with the condition that your friend developed. He has what is called a spontaneous pneumothorax (SP), when air gets in between the lungs and the space around the lungs—not a natural state of affairs—resulting in a change in air pressure inside the chest cavity, with the air pushing on the lung. The lung subsequently collapses a little or a lot and leads to chest pain and shortness of breath of varying degrees, depending on the size of the collapse. With a small, uncomplicated collapse, the person's lung may quickly heal on its own.

Although pneumothorax can occur for no obvious reason, as a cigarette smoker, your friend would be at higher risk for this right away. Known causes of SP include a chest injury, underlying lung disease or ruptured air blisters (blebs). According to the Mayo Clinic website, the following are risk factors for the development of SP:

• Gender. In general, men are far more likely to have a pneumothorax than are women.
• Smoking. The risk increases with the length of time and the number of cigarettes smoked, even without emphysema.
• Age. The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is a very tall and underweight man.
• Genetics. Certain types of pneumothorax appear to run in families.
• Lung Disease. Having an underlying lung disease, especially emphysema, pulmonary fibrosis, sarcoidosis and cystic fibrosis, makes having a collapsed lung more likely.
• Mechanical Ventilation. People who need mechanical ventilation to breathe effectively are at higher risk of pneumothorax.
• History of Pneumothorax. Anyone who has had one pneumothorax is at increased risk of another, usually within one to two years of the first episode. This may occur in the same lung or the opposite lung.

Before I address the value of yogic breathing techniques for SP, I do want to mention a potential downside to yoga and SP. There is one report in the medical journal Chest about a pneumothorax arising in a yoga practitioner who had been doing the pranayama technique called the Bellow’s Breath, which is a fast breathing technique of inhaling and exhaling. Fortunately, this is a very rare occurrence; but you would likely want to avoid that and similar breathing techniques for quite some time after the person’s lungs re-inflate and they get the go-ahead from their doctor to return to normal activity. And in the case of our above SP person, they are at an increased risk of a recurrence of a pneumothorax, so you will need take care.

So what do I think would be a reasonable approach of yoga breath techniques for SP? We do know from a few studies done in India that yoga practices, including pranayama, can be helpful for other lung conditions like asthma and emphysema. That means yoga has been used safely in other people whose lungs that don’t work quite right. To me, this is very encouraging about the overall safety of yoga for lung diseases. One possible unwanted result of someone having a SP might be a reluctance to take even a normal inhalation due to fear of a recurrent collapse. However, practicing a gradual increase in the length of the inhalation and exhalation while monitoring for pain or shortness of breath could effectively re-establish a person’s pre-SP breathing ability. And if you encouraged the breathing to have a gentle quality on both the inhale and exhale portions of the breath cycle, you could also eventually improve the overall deep breathing capacity of your student.

It would likely be important if your student has a type-A personality to observe his breathing while you teach him the technique to verify that the breath is not aggressive in any way.  If you yourself do not do a lot of pranayama in your own practice, I’d really recommend that you find an experienced teacher to work with your student.

As things progress, your friend may be able to do the modern three-part breath that is very commonly taught in all levels of yoga classes in the US (you start by imagining you are filling the belly first, then the lower chest second, and finally the upper chest last, but in one continuous breath without a pause). It is also possible that once a good three-part breath is established, teaching a very mild form of ujjayi breathing could be helpful. Ujjayi mimics the effect of using a device called a spirometer that is used in a different lung condition called atelectasis, which is more a problem inside the lung’s tiny air sacs the alveoli, not a result of a collapsed lung specifically. Again, I’d have the student create a very quite ujjayi sound as you monitor  his work for a while to ensure he is keeping it on a more gentle level.

So, to recap, you could gradually reintroduce the three-part breath. Once that is safely accomplished, you might add in some gentle ujjayi to the three-part breath. And with all beginning breath teaching, I’d recommend starting off with the student lying supine to learn these techniques. To be on the safe side, avoid holding the breath at the top of the inhale, and also the bastrika and kapalabhati forms of pranayama.

 —Baxter

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Friday Q A Yoga for a Sprained Ankle

Q: Nina—how bout yoga for a sprained ankle...got some ideas?

A: Why, yes, thank you so much for asking! Last year Baxter did a three-part series on the ankle that is worth revisiting or visiting for the first time if you’ve never read these posts. So check out Getting to Know Your Ankles, Ankle Sprains, and Recovering from Ankle Injuries.

In part 2, Baxter says that a typical recommendation from your doc is to elevate your foot and leg above the level of your heart, and because there are lots of yoga poses that are done lying on your back with the legs elevated, these poses could assist in the healing process. So in the acute phase of injury, try supported inverted poses such as Legs Up the Wall pose, Chair Shoulderstand, and Easy Inverted pose. See All About Supported Inversions for some other possibilities, and links to instructions for them.

Naturally, while you are recovering and need to keep the weight off your ankle, you will need to avoid standing poses. But there are so many other poses you can still do, including seated and reclined poses. If I were in your situation, I’d continue to practice what I could to maintain my flexibility while my ankle was healing. So try some seated poses, such as hip openers, twists, and forward bends, while keeping your ankle in a neutral, pain-free position. Of course, you’ll want to avoid poses that put pressure on the ankle, such as any variation of Hero pose (Virasana) or Half Lotus (Arda Padmasana). Also, many of our office yoga poses, which you can do seated in a chair, will be suitable for you. Reclined poses, including passive backbends as well as restorative poses, can be very effective at opening your body without putting any stress on your ankle. Again, just be sure to keep your ankle in a neutral, pain-free position. It’s kind of an interesting to challenge to figure out how to practice when you need to avoid aggravating an injury (right now I have a plain old skinned knee, so I need to avoid kneeling—it turns out that comes up more frequently in practice that you might imagine).

If the pain and inconvenience of having a sprained ankle is causing you to stress out—which I imagine it would—add in some stress reduction practices, such as meditation, yoga nidra (see the Relaxation Tracks tab at the top of our page), breath awareness or pranayama, or even just a nice long Savasana. Check the index on the right side of our blog for posts on all these topics.

Once the acute phase symptoms have diminished, Baxter says that you can turn your attention to a more typical asana practice, adding in his seated ankle rolls and alphabet spelling exercises (see Ankle Circles). At this point, you can focus on the strengthening aspects of the poses for the ankle and foot area, so add special attention to activating as many of the muscles surrounding your ankles and feet as you do your standing poses.

—Nina

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Friday Q A Pain After a Knee Replacement Part 2

This week’s question is a follow-up question that came in after the post we did on yoga and knee replacements (see Knee Replacements and Yoga) and Shari's answer to another reader about pain after a total knee replacement (see Friday Q&A: Pain After a Total Knee Replacement). It seems that pain isn't uncommon after a knee replacement, but in this case, the pain is coming several years after the replacement:

Q: My partial knee replacement was April 2007. I started back to Yoga this past summer-one day a week, but I found child pose with the knees wide uncomfortable, but I did do it for a few weeks this fall. I now have some pain in my knee and I'm hoping that I haven’t loosed the cement in the joint. Any help would be appreciated.

A: Thanks for writing in about this new pain in your knee. As always, I am not able to diagnose or prescribe a yoga program for you without first doing a more detailed history and physical exam in person, but I can share some thoughts that come to mind from the situation you find yourself in.

One of the challenging things to discern for new yoga students, or those returning after a long break from doing yoga is: How to gauge if “uncomfortable” is a potentially harmful warning sign from your body? This is tricky, because it may simply be that you are getting some intense sensation feedback from the body as you stretch and strengthen parts of your body that have been neglected for a long time. With the knees in particular, learning to recognize the difference between the healthy stretch sensation of the muscles and connective tissue lengthening versus the compression of the tissues and bones that often happens deep folds of the knee joints is an important skill to cultivate. The compression sensations can sometimes indicate pinching of tissues that could lead to inflammation, injury or bruising that may not resolve quickly or could lead to more chronic pain. It is sometimes hard to skip these poses—like Child’s pose—in a public class since they are so common unless you have an alternative offered by your teacher.  I often suggest that folks with knee pain flip onto their backs and draw the knees to the chest, essentially an upside down Child’s pose. Then almost all the pressure is off the knee joint and usually no pain is felt. The other thing to try is to vary the distance of the knee spread in regular Child’s pose until you find a distance that does feel uncomfortable.

It is also important to recognize that undergoing a knee replacement does not equal having the same healthy knee anatomy and movement you had before the surgery and the underlying knee problem that lead to your surgery. One of my students who had knee surgery to clean out a lot of arthritis damage to his cartilage found that his range of motion was less after the surgery than before, but he was now pain free. His challenge became how to gradually see if he could improve the range of motion without leading to recurrent pain.And another student of mine who had one knee replaced, but also had a second bad knee, found that although the new knee operated normally, the second knee become more painful secondary to the new way he was walking with essentially two very different knees. And sadly, having a successful repair does not guarantee that future dysfunction and pain will not arise.

In this case, it is also important to recognize the effect of the passage of time on both the surgerized knee and your other knee. A substantial amount of time has passed from 2007 until this summer of 2013. And with that the knees can undergo gradual changes in the architecture and function of the joint, such that the repaired knee can undergo undesirable changes, and unrelated changes could also have taken place. It could be that something has loosened in the replaced knee parts, but it could just a likely be some other structure, tendon, muscle or other structure, that could be the source of this new pain. This needs investigating! 

Until you have an exam and get a diagnosis from your orthopedic MD, avoid the positions that create immediate or delayed pain in the affected knee. Poses like Child’s pose include Hero pose, Thunderbolt pose (as well as poses that have just one leg in the deep flexion fold at the knee joint), front knee in Pigeon pose variations, the front knee in deep drop knee lunges, and any Lotus preps or full and half Lotus pose. Even some simple seated poses like Sukasana (Seated Crossed Legs) can be worth avoiding until you know what you have going on. Once you get a clear picture of what is happening, I’d suggest setting up a private session with an experienced yoga teacher or yoga therapist to design a home practice that can address your unique situation.

—Baxter

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Friday Q A Weight and Longevity

Q: I've been following this discussion Being Slightly Heavy Aids Longevity  for a while & would like to hear your perspective (phew! Managed to NOT ask you to "weigh in"). I've read that the numbers are skewed because people who are very sick tend to be under weight, and then there is that group of people that become intentionally underweight because they believe it encourages longevity. Thoughts?

A: No causal relationship exists between body weights (BMI) and death. One cannot predict health and the risk of death from BMI alone as there are several confounding factors that need to be taken into consideration. No doubt, longevity (in terms of mortality rates) is lower among people with BMIs of less than 18 (underweight) or greater than 30 (overweight). Being overweight or underweight puts an individual at risk from several associated diseases. Both Western medicine and Ayurveda agree that too little fat (underweight) or excess fat (overweight) can trigger an entire gamut of health issues that in turn affects the quality of life. I do not see any purpose in having a long lifespan while suffering from diabetes, arthritis, infections, osteoporosis or other health issues. It is for this very reason that I advocate quality of life rather than life span extension. All of us are equally aware about ways to improve our quality of life. In addition, anything in moderation is good and that applies to weight issues as well.

—Ram (Professor Rammohan Rao, Buck Institute for Research on Aging)

A: I am a bit reluctant to “weigh in” (as you well put it), as this is truly a messy issue. First, not all fats are the same. As mentioned in the article, the fat that accumulates in your belly can be quite different than that distributed in other tissues or areas of the body. Fat droplets have been observed to increase in aging bones, for example, although it’s not clear what the significance of this is. There has also been a lot of discussion recently on “brown fat” and its role in health and disease. However, none of these distinctions were considered. Second, I don’t like these types of epidemiological studies. They are typically only correlative, and rarely get to the molecular or physiological underpinnings (if they exist at all). Third, only small differences were observed among the main weight groups (excluding the highly obese). Fourth, BMI is a very crude index. That said, the results of this study are still surprising and suggest that our notions of a healthy weight may need to be reconsidered. Most of us intuitively know this, as we have seen plenty of thin people who look unhealthy while many who fit the category of "somewhat overweight" look real healthy, robust and fit. I remember several years hearing from a seminar speaker that early Alzheimer’s’ patients weighed less than their age-matched non-AD controls. The speaker suggested there might be some type of abnormal metabolic disorder associated with AD that had not yet been identified as such.

With so many possible confounders and variables to consider, it’s pretty hard to make any serious conclusions. Eat healthy, be physically active and put away the scale? Sounds good to me.

— Brad (Professor Bradford Gibson, Buck Institute for Research on Aging)

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Friday Q A Dynamic Poses and the Breathing

Q: I have been enjoying the videos of mini vinyasas that you all have been sharing on Mondays. However, I notice that you give very specific and consistent instructions on how to move with the breath, even though sometimes I’d prefer doing the opposite. Are there any rules or reasons why you recommend them the way you do?

A: This is one of the most common questions I get from students who have never worked with mini vinyasas or dynamic poses before. I was first exposed to these practices when I traveled to India in 2005 to study with TKV Desikachar and his staff of amazing teachers. It was there that I was first exposed—other than doing Cat-Cow pose in my classes back home—dynamic versions of many of the poses I had been holding statically in my Iyengar-style of practice.

In this tradition, in dynamic poses, there is a starting position from which you move into the full pose and then back again, repeating the process six or more times. And there is always a suggested pattern to the breath, which works best with the effect of the pose on the abdomen and the flow of breath. Here is the basic gist:

1. When moving into a backbend, move into the pose on an inhalation and move back to the starting position on an exhalation. For an example, see Dynamic Arms Overhead Pose.   
2. When moving into a forward bend, move into the pose on an exhalation and move back to the starting position on an inhalation. For an example, see Dynamic Downward-Facing Dog Pose.
3. When moving into a twist, move into the pose on an exhalation and move back to the starting position on an inhalation. For an example, see Easy Seated Twist.
4. When moving into side bending poses, do so on an exhalation, moving back to the starting position on an inhalation.  For an  example, see Dynamic Crescent Moon. 
5. When you take your arms up from your sides in dynamic standing poses, usually take your arms out to sides or overhead on an inhalation and lower your arms down an exhalation.
6. When there is a combination of these movements in a longer vinyasa,, you typically combine the five breathing techniques described (although there may be exceptions). For example, in a Dynamic Standing Forward Bend vinyasa, you start in Mountain pose by inhaling as your raise your arms Arms Overhead pose (a slight back bending action), exhale as you come into Standing Forward Bend, inhale as you come back up to Arms Overhead pose, and exhale as you release your arms down to your sides (see Dynamic Standing Forward Bend).

But, why, you may still be asking yourself, do it those ways? The answer is that when your spine moves into a backbend shape, the front of your abdomen opens top to bottom,—allowing your diaphragm to move pretty freely—and the space between the ribs expands a bit, all of which facilitates a good inhalation. When your spine moves into a forward bend or twist, you abdomen is compressed top to bottom—pressing up against the diaphragm—and the space between the ribs narrows a bit, all of which inhibits a good inhalation but assists in good exhalation. Twisting has a similar effect to forward bending. Side bending compresses one side of the abdomen and rib cage a bit, so could also inhibit full inhalation and assist in exhalation. In his book The Heart of YogaDesikachar states it simply:

“The rules of linking breath and movement are basically simple: when we contract the body we exhale and when we expand the body we inhale.”

Now, my students sometimes say they prefer the opposite breathing pattern to the ones being taught, and you can certainly do the movements with the other way of breathing. However, it may not be as easy or efficient for the reasons stated above. You might even try to move into Standing Forward Bend while inhaling deeply to see how that feels. Not so great for me!

I hope these guidelines make your exploration of dynamic poses more enjoyable and make more sense.

—Baxter