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Yoga for Every Body: Experts say yoga can ease pain and improve mobility for people with neurologic conditions. And a disability is no reason not to try it.

Griffin, Katherine

doi: 10.1097/01.NNN.0000482683.19268.a1
Features: Yoga

Experts say yoga can ease pain and improve mobility for people with neurologic conditions. And a disability is no reason not to try it.

WEB EXTRA: To find a yoga class, order a DVD, join a clinical trial, or do a yoga retreat, visit http://bit.ly/NN-Yoga-Extras.

Eight years ago, Tanina Agosto woke up in a body that seemed alien to her. “I went to put on lotion just like any other day, and my entire left side felt dead,” she recalls. “I couldn't even comb my hair.” Over the next 16 months, Agosto struggled with numbness, weakness, pain, and digestive problems that remained undiagnosed and unresolved after multiple visits to her primary care doctor and two chiropractors. It wasn't until Agosto met Albert S. Favate, MD, assistant professor in the department of neurology at New York University Langone Medical Center, that she finally received a diagnosis of relapsing-remitting multiple sclerosis (MS) after results from a magnetic resonance imaging scan and a lumbar puncture.

For Agosto, who is 38 and lives in New York City, the diagnosis was scary and difficult to accept. She was a mixed martial arts practitioner who had been leading a very active life; now she was walking with a cane, falling frequently, unable to continue her job as a dental assistant, and facing the prospect of a lifelong illness with unpredictable symptoms.

About a year after her diagnosis, Agosto attended a daylong event sponsored by a local chapter of the National MS Society. She and other attendees were taught a sequence of yoga poses specifically tailored for people with MS and given a two-DVD set to take home. “I started with chair yoga—which I'd never heard of—because my balance was really poor,” Agosto says. “About three and a half months later, I started feeling confident and strong enough to start doing the floor yoga.”

Today, Agosto practices yoga three to four times a week at a local studio. “I still have flare-ups,” she says. “But I'm pretty functional. I can jog up the stairs to catch a train. After running to catch that train, my leg is on fire, but it's progress.”

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PREPARE TO SUCCEED

Yoga may be helpful for people with neurologic conditions, but it's important to proceed slowly and know your limits, says Allen C. Bowling, MD, PhD, an MS expert at the Colorado Neurological Institute and author of Optimal Health with Multiple Sclerosis: A Guide to Integrating Lifestyle, Alternative, and Conventional Medicine (Demos Health, 2014). That's especially true, he says, for people who have fatigue, sensitivity to heat, impaired balance, joint and bone conditions (including osteoporosis), significant heart or lung conditions, and a history of low back or neck pain. It is also true for people with high blood pressure, clotting disorders, eye conditions, or those who have had recent surgery or are pregnant. Dr. Bowling suggests talking to your physician if you have any of these conditions and asking if any particular types of movement may be problematic for you.

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REAP THE BENEFITS

People with a variety of neurologic conditions who try yoga report tangible physical improvements such as increased flexibility and range of motion, better balance, increased strength, and less fatigue. Some people who practice yoga also notice emotional rewards. “When you have a chronic condition, you have to deal with so many negative emotions,” says Agosto. “Yoga helps quiet my mind.” Researchers have noted yoga's ability to promote relaxation and reduce stress since as far back as 2004, as evidenced by a review article in the Indian Journal of Physiology and Pharmacology by Sat Bir S. Khalsa, PhD, a neuroscientist and associate professor of medicine at Harvard Medical School.

More recent studies corroborate Dr. Khalsa's conclusions. For instance, in a 2012 study in Occupational Medicine, researchers at Bangor University in the United Kingdom found that yoga lowered the perceived stress levels of office workers. And in 2014, researchers from the Mailman School of Public Health at Columbia University and several other US institutions analyzed the evidence backing yoga as a supportive therapy for women undergoing breast cancer treatment. In the study, published in Journal of the National Cancer Institute Monographs, they concluded that yoga can be helpful in reducing stress, anxiety, and depressive symptoms.

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YOGA IS INFINITELY ADAPTABLE

To accommodate the needs of people with limited mobility, yoga teachers—some of whom are also physical or occupational therapists—modify the poses. In chair yoga, for example, participants learn versions of poses that can be done while seated. “Gentle” yoga is geared for people who lack the stamina, strength, or flexibility to do more demanding styles of yoga. In the emerging field of adaptive yoga, teachers are trained to instruct people with all kinds of disabilities by tailoring the practice to what their students' bodies are capable of. For someone who has severe arm and leg weakness, for instance, the teacher would emphasize movements of the head and shoulders, together with breathing exercises and meditation.

“Yoga doesn't mean you have to put your leg behind your head,” says Matthew Sanford, 44, an adaptive yoga teacher in Minnetonka, MN, who was paralyzed from the waist down after a car accident at 13. “It's learning to move with more awareness and mind-body consciousness in whatever body you find yourself in. I know of no neurologic condition that isn't helped by that.”

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RESEARCH ON THE RISE

There aren't many studies on yoga for neurologic conditions, but over the past decade or so interest in this area of research has increased. “Most of the studies are pretty small, but it's exciting,” says Arlene Schmid, PhD, an occupational therapist at Colorado State University who has studied how yoga may benefit people with stroke, traumatic brain injury, and chronic pain. Although few of the trials are randomized and controlled—the gold standard for assessing the effects of a practice or therapy—several have shown encouraging results. Some have examined how yoga affects people with particular neurologic conditions; others have documented benefits in other populations that are likely to extend to people with neurologic disorders as well.

The emerging research, along with the fact that yoga is a fairly low-risk activity, has persuaded some neurologists to recommend it to their patients, says Barry Oken, MD, FAAN, a neurologist at Oregon Health & Science University in Portland, who published one of the first randomized controlled trials of yoga for multiple sclerosis in the journal Neurology in 2004. Yoga also promotes flexibility, which can be helpful: “Limited range of motion in joints occurs in a lot of neurologic disorders,” Dr. Oken says. “Anything that would preserve range of motion would be useful.”

To learn more about the potential physical and emotional benefits of yoga, we looked at the research and talked to yoga teachers and students and physicians. Here's what we found.

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7 WAYS YOGA MAY HELP

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1 IMPROVED BALANCE

In a pilot study of yoga among people who had had strokes, led by Dr. Schmid, and published in 2012 in Stroke, participants who took part in an eight-week group class significantly improved their scores on a test that assesses balance. Those who attended every class boosted their balance scores the most. And in a 2015 randomized controlled trial, University of Miami researchers compared a high-speed version of yoga (in which participants moved quickly from one pose to the next) with a low-resistance form of weight training in a group of 42 people with Parkinson's disease in their 60s and 70s. That study, published in Archives of Physical Medicine and Rehabilitation, found that both types of activity improved balance as well as motor scores (a measure of movement ability) and walking speed.

“If we improve balance, it leads to a lot of other changes,” Dr. Schmid says. Some participants in her studies, for instance, said they felt more confident about socializing outside of their own homes and their overall quality of life improved.

That makes sense to Renee Le Verrier, 54, who has Parkinson's disease. “More than anything else, yoga improves awareness of my balance,” says Le Verrier,. “I may still tip over, but I won't fall face-first. I know where my body is in space.”

Le Verrier began doing yoga when she was 32, in part to help with residual weakness on one side of her body from a childhood stroke. She found it helpful, and after her diagnosis of Parkinson's disease in her early 40s, she turned to yoga in a whole new way.

“After I was diagnosed, I did a physical therapy program that was all inclusive—occupational and speech therapy, a pool, a social worker,” she says. “I said to one of the therapists, ‘The only thing missing is yoga.’ She said ‘Well now, who could teach that?’”

That conversation inspired Le Verrier to enroll in a yoga teacher training program. She now teaches yoga for people with Parkinson's disease and other movement disorders. When teaching, she tries to link the movements students do in class to their everyday activities. “I'll say, ‘This is how you load the dishwasher—instead of turning and twisting, turn your whole body,’” she says.

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2 INCREASED STRENGTH

Along with improved balance, one of the biggest benefits Le Verrier sees is increased physical strength. Yoga can strengthen muscles by using the body's own weight as a form of resistance. For her students with Parkinson's disease, Le Verrier often focuses on poses that build strength in the muscles of the back. “Strong back muscles may help counter some of the involuntary flexing that happens,” she says.

As the disease progresses, adaptive yoga teachers like Le Verrier modify the practice to make it less demanding: For instance, a student who may be able to handle certain standing poses at first may need to transition to doing poses only while seated. Le Verrier says that she has shifted her own yoga practice from an hour at a time to 10-minute sessions two or three times a day. “That works better for me because my ‘on’ window [the period when the medication is effective] is shorter,” she says.

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3 ENHANCED FLEXIBILITY

With its emphasis on stretching, it's not surprising that yoga would also increase flexibility. Studies in various populations have shown this; for instance, in a 2006 randomized controlled trial of 135 healthy people aged 65 to 85 published in Alternative Therapies in Health and Medicine, Dr. Oken found that those who practiced yoga for six months improved their flexibility. Sharon Krischer, 63, knows this firsthand. She started practicing yoga shortly before she was diagnosed with Parkinson's disease six years ago and has been able to continue even as her symptoms have progressed. Doing yoga in the morning, she says, allows her to move with more ease throughout the day.

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4 LESS FATIGUE

For many people with Parkinson's disease and other neurologic conditions, symptoms of fatigue and low energy make exercise unappealing. In fact, in one study of more than 400 people with MS, published in Disability and Rehabilitation in 2013, participants said that fatigue was one of the top barriers to exercise.

Because of its adaptability, yoga may help sidestep this problem. People can practice it in a chair, a bed, or a wheelchair, and the poses can be adjusted to accommodate different levels of fatigue, pain, or stiffness. “I do recommend yoga to my patients,” says Roy Alcalay, MD, an assistant professor of neurology at the Taub Institute, the program director of the Movement Disorders Fellowship at the Columbia University Medical Center, and a medical advisor with the Parkinson's Disease Foundation. He says yoga is helpful because it has so many variations.

People who come to a class without much energy can still benefit from a quiet, low-key session, teachers say. Yoga's emphasis on body awareness can help students stay within their limits during each session, which may reduce the chances of becoming overtired. And some studies have found that keeping up a steady practice can boost overall energy: In his 2004 study of yoga and MS, Dr. Oken and his colleagues found that a six-month yoga program reduced fatigue, as reflected by the participants' scores on a questionnaire designed to measure fatigue. Other studies have since corroborated the finding. In one, published in Multiple Sclerosis Journal in 2012, researchers from the University of Limerick, Ireland, found that 77 people with MS who did yoga for 10 weeks also reported less fatigue, as measured by scores on a fatigue scale.

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5 DECREASED STRESS AND ANXIETY

Stress is especially problematic for those living with a neurologic illness as it can cause symptoms to flare up or intensify. “Psychological stress may worsen MS,” says Dr. Oken. “In Parkinson's, stress may worsen tremor. So anything that reduces stress might improve the symptoms.”

Stress reduction is one of the best-documented benefits of yoga. Practices that teach people to pay attention to the current moment in a nonjudgmental way—mindfully observing what is happening without getting caught up in it—have been shown to help with anxiety, stress, and depression in large numbers of review studies, says Dr. Oken. And numerous studies have shown that yoga can promote relaxation and lower blood levels of stress hormones such as cortisol, says Teshamae Monteith, MD, FAHS, assistant professor of clinical neurology at the University of Miami Miller School of Medicine.

For people with neurologic illnesses, reducing stress may help with both physical and mental symptoms. Yoga teaches people to bring awareness to stress-promoting body sensations and habits that they might otherwise overlook—clenched muscles in the neck and shoulders, for instance, or shallow, rapid breathing. Learning to recognize and counter these patterns can short-circuit the stress response and bring both a greater sense of physical ease and a calmer outlook.

Lauren Williams of Baltimore says yoga's mind-body principles help her manage stress and anxiety. Diagnosed with Friedreich's ataxia when she was 10, Williams has used a wheelchair since she was a senior in high school, and has difficulty with balance and coordination. (Friedreich's ataxia is a rare inherited disease that causes nervous system damage and movement problems.) Now 28, she says practicing the physical poses has improved her posture, manual dexterity, and balance; and practicing the breathing and meditation techniques has helped keep her calmer. “After a fall, sometimes I would have anxiety attacks,” she says. “Now, I can manage my stress and anxiety a lot better.”

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6 BETTER PERSPECTIVE ON PAIN

Yoga may also help people cope with pain. In a 2013 randomized controlled trial published in the Clinical Journal of Pain, German researchers from the University of Duisburg-Essen compared yoga with a self-care exercise program among 51 people with chronic neck pain. (The self-care group received a manual of exercises they were instructed to do at home.) The researchers found that yoga reduced the participants' pain scores by more than half. And in a randomized controlled trial of 72 people with migraine headaches done in India, published in Headache in 2007, those who practiced yoga for three months had fewer headaches than a comparison group who practiced standard self-care.

“Yoga integrates well with conventional medicine,” says Dr. Monteith, who specializes in migraine. “It's not either/or—the combination is powerful.”

Danielle Bernard, 36, has been living with chronic pain since she broke both legs and suffered severe bruising and cuts on her arm when she was hit by a car in 2006. Since the accident, her arms have continued to hurt, which doctors attribute to nerve damage. She was recently diagnosed with chronic regional pain syndrome in her hands and says that on a scale of one to 10, most of the time her pain level hovers around seven or eight.

“I definitely think yoga changes how I'm processing pain,” says Bernard, who lives in Windsor, CO. Bernard says that by cultivating the “witness mind” that yoga encourages—stepping back and observing thoughts and perceptions rather than getting caught up in them—she is better able to cope with her pain. “It sounds funny, but when certain pains come up, I can talk to them. I say, ‘I know this is my pain body speaking—you need to calm down a little bit.’ I can say that, and it will calm down.”

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7 SELF-ACCECPTANCE

One of yoga's most valuable principles may be self-acceptance. Le Verrier still vividly remembers her first encounter with this principle, well before her diagnosis. “Walking us into a pose, the teacher said, ‘Whatever you do is fine, don't judge it,’” Le Verrier recalls. “And I'm like, ‘Don't judge it? Wait, what?’ I was always comparing what I was able to do. I didn't realize I was doing it until he said that.”

Learning to do the poses from the inside out—“with the body you have, not the body you wish you had,” as Matthew Sanford puts it—is important for anyone who practices yoga, but especially for those with physical limitations. It's a matter of safety as well as an essential part of making peace with your body.

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STAY WITHIN YOURSELF

In the classes Sanford teaches, he makes a point of emphasizing that students pay close attention to the moment-to-moment sensations in their bodies. This can build students' awareness of their own limits and help them to practice safely. “If you try to go faster and harder, despite your condition, you're going to aggravate it,” he says. “The emphasis is not on trying to do more. The emphasis should be on how you move.”

Ryan McGraw, a 32-year-old disability rights advocate with cerebral palsy, who lives in Chicago, has been practicing yoga since he was 19. “As people with disabilities, we are always trying to push ourselves to be better,” he says. “With yoga, you can take a step back and be okay with your body.”

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UNIVERSAL PRINCIPLES

Matthew Sanford says he has experienced many of yoga's benefits in his 25 years of practice and 19 years of teaching.

He first tried yoga when he was 19, six years after the car accident that severed his spine, paralyzed him from the waist down, and killed his father and sister. Early in his rehabilitation, as he and his medical team focused on building his upper body strength, Sanford felt cut off from his lower body, as though it was nothing more than dead weight he had to learn to drag through life.

Yet as he began to practice yoga—haltingly at first, feeling his way along with a teacher willing to explore how to adapt poses for him—he began to find a sense of connection to his lower body, an aliveness there. “With such a limited repertoire of poses, I was forced to learn from the subtle differences between them,” he writes in his memoir, Waking: A Memoir of Trauma and Transcendence (Rodale, 2006).

Since then, practicing yoga has profoundly changed the way he inhabits and experiences his body. “The principles of yoga hold for my body the same as for anyone else's,” he says. “The outer expression just looks different.” In his wheelchair, he can move his arms and shoulders into the upper-body elements of many yoga poses. And sitting on the floor, he can use his arms to move his legs into position for poses like forward bends.

Sanford went on to found Mind Body Solutions, a nonprofit organization in Minnetonka, MN, that promotes adaptive yoga. He has taught students with cerebral palsy, spinal cord injuries, Parkinson's disease, amyotrophic lateral sclerosis, and many other neurologic conditions.

In his teaching, he often guides students to become aware of four sensations: grounding, balance, expansion, and rhythm. Students may not have muscle control, or even the ability to move, but Sanford says that these elements are at the heart of yoga and accessible to anyone. “You start to show them that there's an easier way to live in their bodies,” he says. “Then, experientially, they start to understand. The poses show them.”

“No matter what condition you're living with,” Sanford says, “if you do a better job of living within your body, you're going to see benefits.”

© 2016 American Academy of Neurology