Most individuals with spinal cord injury (SCI) caused by trauma or disease are forced to adopt a sedentary lifestyle that's often in stark contrast to their lives before the SCI. What's more, the decreased activity level contributes to secondary impairments and a further decline in functional activities.
An exercise program geared toward helping individuals with SCI remain functional in their daily activities is a key part of rehabilitation. In a recent study, nearly three-quarters of the individuals with SCI expressed an interest in participating in an exercise program. But fewer than half of those surveyed were actually involved in one. Those who weren't said that they didn't know where to go to exercise or they lacked access to appropriate facilities and knowledgeable instructors.
That's understandable: individuals with SCI have special needs when it comes to exercise. Gym-based programs have their place, and individuals with SCI can engage in and benefit from general fitness programs. But issues of safety can arise if the gym staff isn't trained to deal with issues surrounding a disability. Plus, equipment in the gym may not be adaptable to the needs of individuals with SCI.
This is where your expertise as a therapist comes in. As a rehabilitation professional, your expertise is invaluable in developing short- and long-term physical activity programs that involve interventions appropriate to each person's particular condition, allowing that individual to exercise safely.
One area of exercise that will allow you, as a therapist, to apply sound therapeutic principles when working with individuals with SCI is yoga. Yoga, specifically Iyengar yoga, can easily be integrated into an exercise program. This type of yoga addresses strength, flexibility, and physical balance through stretching of the muscles.
I've had good functional outcomes and great feedback over the years when integrating Iyengar yoga into exercise programs for SCI clients I've worked with. In this article, I'll describe the program and discuss its therapeutic benefits.
As a rehabilitation specialist, you understand the challenges inherent in designing an exercise program for individuals with physical issues caused by SCI. These individuals have joint contractures or permanent limitations of joint movement due to poor positioning, lack of movement, and/or muscle spasticity. Muscle atrophy and osteoporosis may also be present.
Areas of concern aren't limited to bone and muscle. Decreased respiratory function can increase the individual's risk of respiratory infections, congestion, rapid breathing, and shortness of breath. Pain is a major issue for individuals with SCI, even years after the initial trauma or illness. Sensory deprivation—an inability to accurately determine the nature of stimuli at or below the level of injury—is also common among this population.
Mobility remains the area of greatest concern among individuals with SCI; in fact, decreased mobility has been rated the most difficult consequence to deal with after injury. Consider that individuals with SCI sit for long periods of time. Because of that, they lose range of motion in major joints, such as the hips, knees, and ankles. This loss has a negative effect on functional activities, such as lying supine or prone or even standing passively. Severe reductions in passive joint movement aren't always acknowledged and addressed in traditional exercise programs.
That's how yoga can benefit these individuals. It encompasses meditation, relaxation, breathing control, and a variety of postures (or asanas, in Sanskrit). Other forms of exercise usually involve limited motion of just a few joints—for example, the arms and legs are predominantly used in cycling and swimming. In yoga postures, all the joints of the body are used and kept mobile.
As I mentioned, the type of yoga I practice and integrate into rehabilitation for clients I work with is Iyengar yoga. It's part of a yoga method or style for developing physical and mental well being through stretching and activating all of the muscle groups to gain strength, flexibility, and physical balance.
Iyengar yoga (which was named for B.K.S. Iyengar, the master yoga teacher who developed the method) has three defining characteristics: alignment, sequencing, and timing. Alignment is the precise and often subtle technical point given to assist and explore correct posture fully. Sequencing is the order in which the postures are followed during the session. Timing is the length of time the postures are held.
Adopting some of the tenets of Iyengar yoga therapeutically can promote natural relaxation and prepare the individual to take on a more rigorous Iyengar yoga exercise regimen. And as individuals with SCI are encouraged to “look inside” and concentrate on their breathing during the yoga practice, they become aware of a deep and positive mind-body experience. The therapeutic focus here is an outcome of improved functional activity.
For many reasons, I've found the Iyengar style of yoga to be more adaptable to individuals with special needs than other yoga styles. For example, this style of yoga methodically introduces a limited set of postures. Special attention is given to the correct alignment of the body in each pose while promoting a self-awareness of the inner workings of the body. Poses can be modified as needed, and props, such as blocks, sandbags, blankets, and chairs, can be used.
For individuals with SCI, who often have tone abnormality, introduction of certain passive, or assisted, yoga postures can invoke a relaxation or release phenomenon throughout the individual's trunk and extremities. The muscles then become more adept at balance control and active operations.
Postures can instigate some initial muscle resistance, mostly due to spasticity from the abnormal tone and/or soft tissue limitations. This resistance is usually overcome once the client is in the correct position with prop support. The eventual stretch or elongation of the client's muscles then prompts a release, and after about 30 seconds, the client feels the body accept the relaxation. The degree of stretch tolerated depends on the condition of the client's joints and muscles, as well as his or her mood and emotions.
The finer points
Next, I want to give a brief overview of a rehabilitation exercise session in which I integrated Iyengar yoga. Keep in mind that specialized knowledge is needed to implement this technique. The B.K.S. Iyengar Yoga National Association of the United States, the governing body that oversees the training of Iyengar yoga teachers, recommends that only advanced-level Iyengar yoga teachers work therapeutically with clients with SCI. If you're interested in learning this technique, the association has centers across the country that can provide instruction for physical therapists and other rehabilitation specialists. Special workshops for therapeutic applications instructors are also available.
I advise therapists interested in implementing this approach to learn through their own experience—in other words, by practicing this type of yoga, you can learn the principles that you'll apply to your client sessions. You might also want to collaborate with an experienced Iyengar yoga teacher who can give you invaluable guidance in your pursuit of integrating Iyengar yoga and rehabilitation.
Now, let's look at how I integrated Iyengar yoga into a rehabilitation program for one of my clients.
AJ sustained a gunshot wound 10 years ago that left him with paraplegia at the level of T4. He underwent a stabilization procedure. Presently, he uses a manual wheelchair for all of his mobility needs. He is independent in all activities of daily living, including self-catheterization. He was referred to me with shoulder pains bilaterally and lower back pain. My evaluation of him revealed the following:
* spasticity and spasms in his lower extremities, characterized by difficulty in passive movement and rigidity of the affected areas
* severe limitation in the range of motion of his lower extremities, including an inability to separate his knees more than 4 inches apart
* hip flexion contractures that limited his ability to lie in a prone position
* knee flexion contractures that limited his ability to sit in a long sitting position (with his legs extended) when in bed
* mild limitation in the range of motion into plantar and dorsiflexion in both ankles. The decreased tone in this part of the lower extremity—especially in the frontal plane—caused inversion instability, making transfers from the wheelchair unsafe.
* overall strength of 5/5 with normal grip strength of 80 pounds in the upper extremities
* range-of-motion limitation in the shoulders at the end ranges of elevation and rotation, followed by severe pain
* fair trunk balance; upper extremity function depends on trunk and pelvis stability.
After the evaluation, I set the following goals for AJ's therapy:
* Reduce spasticity through positioning so that activities of daily living wouldn't be interrupted by episodes of spasms.
* Increase passive range of motion at the hips so that hygiene care will be manageable. This will also allow for prone positioning.
* Increase flexibility, strength, and proper alignment of the shoulder girdle to reduce pain intensity and frequency and to improve activities of daily living.
* Explore weight-bearing activities to reduce the risk of lower extremity fractures.
* Explore the use of orthoses to stabilize the ankles for safer transfers and weight-bearing activities.
The Iyengar yoga session
I integrated Iyengar yoga into AJ's rehabilitation sessions to help improve his strength and flexibility, as well as to improve his awareness, relaxation, and self-reflection. We talked about the potential benefits, and AJ expressed his willingness to try this integration of Iyengar yoga into his rehabilitation program.
Our sessions started with AJ seated in his wheelchair, facing a stall bar (modified virasana position). In this position, he could actively assist in correcting his sitting alignment. His knees were positioned against padding on the stall bars; this helped AJ create a better alignment for himself. He could also grab a bar with his hands to help him align his pelvis and trunk. His feet were supported on blocks, which allowed him some sensory feedback despite his impairment and helped him keep his ankles aligned correctly.
AJ was then guided to transfer onto a treatment bed to lie supine (supine virasana position). One of my concerns was that individuals with SCI may have difficulty with this position because of hip contractures. The thighs don't lie flat on the bed surface (Figure 1). This position can trigger spasticity and spasms too.
With these things in mind, I used a blanket and a belt to support AJ's thighs (Figure 2). The weight of his legs then helped to relax and elongate his muscles. Over time, his hip contractures lessened.
The session continued with the supine savasana position. A bolster was placed beneath AJ's knees and a block was placed between them; his ankles were supported with orthoses to hold them in good alignment (Figures 3 and 4). This pose is held for 5 to 10 minutes to enhance relaxation of the legs and the rest of the body. It allowed AJ to deepen the relaxation with slow, deep breathing.
Next, AJ was turned on his stomach for a prone savasana position. Hip and knee flexion contractures—an issue for AJ—can make this pose difficult; the pose extenuates lumbar lordosis. To counteract this problem, props were placed under AJ's hips, knees, and ankles to improve alignment and comfort and to elongate the areas of his body with contractures. After his body settled and his range of motion improved, active and assisted active postures were encouraged.
Toward the end of the session, AJ was guided into the paschimotanasana pose; as the posture is held, the hamstrings and lower back extensors are stretched and elongated. Orthoses helped AJ achieve better control of the alignment of his lower legs.
Better level of functioning
As a therapist, you're in a great position to help your clients with SCI understand the importance of committing to an exercise program. Yoga, specifically Iyengar yoga, can be integrated into that program to address issues of strength, flexibility, and physical balance. By taking into account the special needs of your clients with SCI, you can get them moving toward a better level of functioning in their daily lives.
Tips for teaching Iyengar yoga
Collaboration with an experienced Iyengar yoga teacher will give you invaluable guidance in your pursuit of integrating Iyengar yoga into rehabilitation of a client with a spinal cord injury. The collaboration I have with my Iyengar yoga teacher, Mary Dunn, includes meeting at the clinic and observing and discussing application of this integration. The ongoing learning experience has led to an exciting exchange of ideas and improved practical applications. We've even shared these ideas with other therapists in meetings like the annual meeting of the American Physical Therapy Association.
Here are some of Mary's insights to help therapists understand and integrate therapeutic aspects of Iyengar yoga:
* Treat the whole person.
* Empower the client.
* Adjust yoga to the way all can do it.
* Sequence postures to enhance and build effectiveness.
* Teach sensitivity to alignment and function.
* Use weights and timings to lessen contractures.
* Use asymmetrical poses or symmetrical postures in an asymmetrical way to gain flexibility and awareness of structure and functionality.
* Teach intricacies and be aware that the intricacies have effects far from the site of intervention.
* Teach breathing function, control, and mechanics as well as how to use breathing muscles, including the diaphragm.
* Integrate breathing into active and passive postures.
* Understand that passive postures are not necessarily passive. They provide the venue and time to allow things to happen.
* Sequencing prepares and builds abilities and compliance in range of motion and strength and positioning sense.
* Teach as well as treat so that the client can apply what is done in the session to daily life and home practice.
* Take maximum advantage of what's possible and envision more possibilities than are on the surface.
* Use weight-bearing postures in different orientations and different bases of support.
* Teach the muscles to consciously support weight bearing and coordinate with other muscle groups to share the burden of support.
* Focus on increasing circulation, with all of its benefits.
Dalia Zwick, PT, PhD, is Senior Rehabilitation Supervisor, Premier HealthCare, New York, N.Y.
Acknowledgment: The author wishes to thank Mary Dunn, senior lyengar yoga teacher, for her valuable contributions to this article.© 2006 Lippincott Williams & Wilkins, Inc.