You’ll Be Ready to Move After This Short Series of Spine Stretches

This was originally published in Yoga Journal. Read the original story and watch the video here.

Dr. Ingrid Yang, yoga teacher, yoga therapist, and YJ’s September/October cover model, shares a 4-minute practice to warm-up your spine.

It’s been said that you’re only as young as your spine is flexible, and there’s some truth to that. The spinal cord holds our lifeforce energy, so warming it up properly before any form of movement—including yoga—not only helps unleash that energy, but also supports your spine’s health (and yours).

In this short practice, Dr. Ingrid Yang—yoga teacher, yoga therapist, and YJ’s September/October cover model—guides us through stretches that move your spine in every direction, so you’ll be ready to flow.

This Doctor Pioneered a Breathing Technique for COVID-19 Patients

This article was originally published in Yoga Journal. Read the full article here.

There’s only one window in the hospital room. It doesn’t open, but it stretches nearly the entire length of the wall, from built-in bench to ceiling, inviting light into the otherwise stark space. A large treble clef sculpture centers a modest fountain in the courtyard outside. On one of San Diego’s classic unseasonably warm April mornings, the air catches and carries the dancing water droplets to the ground. Inside, an orchestral performance of a different sort unfolds.

Here, in the COVID unit of Sharp Memorial Hospital, mechanical whirring replaces the string section, pumping medical devices sub for the woodwinds, and a sharp, irregular intake of crackling breath establishes the bass rhythm. This last instrument belongs to Vernon, a man in his 60s who was diagnosed with COVID-19 two weeks prior. Tubes in his nostrils meet in a V under his chin where they flow to the oxygen tank sitting at his side. His eyes are closed, his maskless face relaxed, hospital sock–adorned feet planted evenly on the ground as he sits in front of the window, the treble clef fountain at his back.

Knee to knee with Vernon sits hospitalist-physician Ingrid Yang, MD. Her hands gracefully carve the space between her and Vernon, gesturing as she conducts a symphony of yoga therapy. “We’re going to inhale through the nose, three, two, one,” she says, drawing her hands slowly upward as together she and Vernon expand chest and belly. “Hold for a count of three, two, one. Exhale through pursed lips—try to depress, use the contraction of the diaphragm—that’s nice.”

There’s a musicality to Yang’s presence, from her bell-clear voice and cadence of speech to the rhythmic way she moves through the world. A trained Reiki healer, she’s a master of shifting energy—almost visibly sculpting it at all times, knowingly or not. She gestures continuously as she speaks, leading Vernon through a pranayama-based protocol she developed that’s so simple it could easily be dismissed. But when dealing with a virus that steals breath from those it infects, where the dominant prescription has been isolation, breathing together creates a life-changing connection for Yang and her patients.

Heart uncentered

After emigrating from Taiwan in the 1970s, Yang’s parents—Christine, an attorney, and James, a physician—settled in Newport Beach, California. As immigrants, they had to adjust their priorities, Yang says, replacing sentiment with success in order to survive—a way of life they instilled in Yang and her older brother as well. “Surviving means having job security, and a title so that you’re indispensable enough to not be marginalized,” Yang says.

Feelings were neither tolerated nor nurtured in her home, so Yang buried hers. She learned to play the role others expected of her as an Asian-American girl, to be “good” and “quiet”—but as a result, an internal disconnect grew: Intellectually, Yang understood her value as a motivated, high-achieving young woman, but she struggled to embody much beyond that emotionally.

At 18 years old, she found herself an anxious, type-A freshman at Barnard College of Columbia University in New York City. She tried a few yoga classes at a friend’s recommendation, but struggled to connect to the practice.

And then, it happened: One day in class, Yang moved into Trikonasana (Triangle Pose). She turned her head to bring her gaze to the ceiling, breathed into the posture, and felt an unfamiliar lightness. A knowing spread throughout her, that she didn’t have to be anywhere or accomplish anything, that she could simply breathe.

“It was the heart expansion,” says Yang, who’s now E-RYT 500 and C-IAYT certified, and who co-authored the book Adaptive Yoga last year. “The actual physical space of my heart, then taking a breath as I expanded the heart and connecting that thought, physical space, and breath. It all suddenly came together.”

At the same time that Yang was exploring this new relationship with yoga, she also developed a bond with her Aunt Shiu-mei, who worked in a lab at Columbia. Shiu-mei brought her niece lunch and helped her with homework. When Yang needed a break from the city, she decamped to Shiu-mei’s New Jersey home for a weekend of cooking, eating, and talking. Where Yang’s parents had been all work and no play, Shiu-mei’s life was full of social outings and travel, of joy and independence. Shiu-mei gave Yang something she hadn’t before experienced—a soft, nurturing kind of love.

Dharma realized

Over time, yoga helped Yang reconnect with the heart she’d been discouraged from nourishing for so long. After completing her yoga teacher training in 2005, she started leading vinyasa classes—something she continued all the way through law school at Duke University and into her first year as a corporate lawyer back in New York City.

In 2005, Yang was 25 years old, making six figures, and killing it by her parents’ standards. But her gut wasn’t sold on this version of success. Then, while in Canada at teacher training, she got a call: Aunt Shiu-mei, who had recently developed idiopathic pulmonary fibrosis—a lung condition that makes breathing incredibly difficult—had suffered a stroke.

Immediately, Yang booked a flight to be at her aunt’s bedside. When Shiu-mei took her final breaths, her niece was there. “Her passing lit both a light bulb above my head and a fire under my ass,” Yang says. Hit by the quickness and fragility of life, she walked away from practicing law, which she’d never truly enjoyed, a few months later. She returned to North Carolina to open a yoga center. “For the first time in my life, I actually followed my instincts,” she says. Her parents looked on in fear, Yang says, believing their daughter was trading in her laudable career to become a gym teacher.

Blue Point Yoga opened directly across from Duke Medical Center in 2006 and was a fast success. The nurses, doctors, and specialists who filled Yang’s classes were curious, posing all sorts of questions about the mechanics of the practice that she didn’t feel equipped to answer. So she researched anatomy and kinesiology in her free time and discussed science in her instruction. Yang loved learning about the intrinsic relationship between yoga and science. She confided in an old friend, who was an oncologist at Duke, that if she could do it all again, she’d be a doctor. “What do you mean, do it all again?” the friend replied. “You’re 27! You still can.” It was all the encouragement Yang needed. In August 2011, Yang entered medical school at Rush Medical College in Chicago.

An inflamed response

The summer of 2020 passed in a haze of disconnect. Uncertainty sat on the shoulder of every decision made, colored by a draining combination of simultaneous information overload and asphyxiation as Yang, in her second year as an attending physician with Sharp-Rees Stealy Medical Group, and her fellow health care workers grasped for any bit of intel that could shift the wind.

Dozens of beds were filled in the COVID unit at Sharp Memorial, hidden behind two sets of doors that Yang could enter only after adorning herself in full PPE. Inside the unit, Yang would stand outside her patients’ doors before entering, watching them gasp for breath, even with the help of a machine. Looking through the door’s window, Yang realized she was mirroring her patients: She had stopped breathing.

Instinctively, her yoga training kicked in. Yang began taking a few breaths to ensure she was present before entering each patient’s room. “Taking this deep breath before I went in was an acknowledgement—that this is really hard, this is all really, really difficult—and then, in that process of caring for myself, being able to let it go and leave it at the door so I could really be there with my patients,” Yang says. It helped. Soon, she wondered whether simple breathing exercises could help her patients, too.

Breathing into Discomfort

COVID-19 starts as an infection in the respiratory system, a nexus that stretches from nose to lungs. Medical experts hypothesize that when your body detects the virus, it reacts with persistent inflammation—a self-healing response that simultaneously throws the body into a constant state of high alert, which in turn wreaks havoc on your organs and tissues, such as those your respiratory system relies on for oxygenation. But yoga practitioners like Yang know there’s a breadth of research to support a different solution.

“Yoga is uniquely suited to assist with COVID-19 recovery,” Yang says. “All the techniques we’re using in pulmonary rehab—comprehensive treatment program for people with acute lung injury—are yoga techniques. We’ve been doing pranayama, we just haven’t been calling it that

Yang is referring to the large body of research supported by the National Institutes of Health on the negative link between yoga and inflammation. A 2012 study, for instance, showed that people with more-regular yoga practices have lower levels of the chemical leptin, which encourages inflammation, and higher levels of adiponectin, which inhibits it. So, Yang hypothesized, yoga ought to be able to help treat the inflammation that causes COVID patients’ most damning symptoms.

When Yang first brought breathing exercises to her COVID-19 patients, she wasn’t intending to treat the virus specifically, but to help her patients feel better generally, to enjoy and benefit from some sense of connection (to Yang, to an activity, to their breath). But the more she incorporated pranayama into her rounds—encouraging her patients to take a mindful pause and a series of deep, diaphragmatic breaths—the more her lens shifted and the practice evolved from an exercise into a protocol. By applying a yogic scope to diaphragmatic breathing, Yang realized she would have two rich bodies of work to reference—her yoga training and her medical training—the marriage of which could guide others in working with COVID-19 long-haulers, as she writes about in the winter 2021 issue of Yoga Therapy Today.

“Diaphragmatic breathing exercises can work to strengthen weak respiratory muscles,” writes Yang about pulmonary complications. “After all, the diaphragm is a muscle, and people often experience global weakness post-COVID. Exercising and strengthening the diaphragm will benefit any postviral syndrome or inflamed physiology. … The primary goal is to strengthen the lungs and their supporting musculature; the secondary benefit is relaxation and activating the parasympathetic nervous system.”

More recently, Yang has been meeting with the hospital’s physical therapists to discuss how to implement the breathing practice more widely, and regularly lectures via webinars to help educate yoga therapists when it comes to aiding their patients with recovery.

Yoga therapeutics for COVID-19 go beyond breathing-related manifestations, Yang says. Movement helps ease vascular blood clots caused by virus-caused tissue damage and inflammation; the lung expansion that comes with Salabhasana (Locust Pose, also called “proning” in the medical field, and a favorite recommendation of Yang’s) soothes musculoskeletal complications; and mindfulness meditation or yoga nidra serves as a powerful therapy for the emotional trauma and disconnect that COVID-19 leaves in its wake.

Underlying each therapy, no matter the symptom or cause, is connection, and in this way, yoga serves one of our most basic human needs.

“In some ways, it’s my job to save lives, which is a little hyperbolic—most days I’m just helping people get through their chronic medical issues. But if I can give them a piece of what saved my life, my self-worth, my heart…” Yang trails off. “We underestimate the degree to which connection and heartfelt love and permission to feel can affect people’s healing, and yoga gave me that permission.”

Not Just a Pain in the Brain: Yoga Therapy and Headache Disorders

Originally published in Yoga Therapy Today, a publication of the International Association of Yoga Therapists (www.iayt.org). Shared with permission.

Headaches are a universal human experience. According to the World Health Organization’s (WHO) 2016 Fact Sheet on Headache Disorders, 50%–75% of people over 18 suffered from a headache within the previous year. Of the people reporting, 30% described their headaches as migraines—and migraines rank sixth in the world for losses due to disability, from productivity and wages to quality of life. More painful to note: As many as 4% of people worldwide are estimated to have 15 or more “headache days” per month. Finding relief for patients suffering headaches has been the goal for Western medicine as well as holistic care. 

Headache Types and Pathologies 

The limbic system is involved in the emotional, behavioral, memo ry-storage, and fear responses to pain. The ventrobasal (front-lower) portion of the thalamus sends projections to the somatosensory cor tex, where pain discrimination (sensing of contrasts) and localiza tion are thought to occur. The medial (closer to the center) thalamus projects to the frontal cortex, where the affective and motivational responses to pain are believed to be mediated. In addition, evidence from positron emission tomography (PET) scans shows that the medial thalamus may participate in the transmission of both dis criminative and affective components of pain.1 This complex network demonstrates the importance of the thalamus in the prop agation of headache pain. Nonetheless, there are many causes of headache pain that should be understood by the yoga therapist—I will delineate below based on the type of headache. 

Headaches fall into two cate gories, primary and secondary, with the assigned category relating to the underlying pathology. By definition, pri mary headaches are not associ ated with any type of preexist ing medical condition and comprise the overwhelming majority of recurring head aches. Given their high preva lence, this article will focus on primary headaches. There are three main types of primary headaches: migraines, tension type headaches (TTH), and cluster headaches. 

Particularly in primary headaches, meditation has been found to decrease headache intensity and frequency with no associated side-effects. 

Under normal physiological conditions, the brain itself is large ly insensate. Head pain occurs when nociceptive nerves (inflamma tion/chemical damage receptors) within the trigeminal, vagus, and glossopharyngeal cranial nerves (three of the cranial nerves) or the upper cervical roots are stimulated.1 To describe this phenomenon in scientific terms, from the trigeminal nucleus (the cell origin of the largest cranial nerve), nerve fibers transmit information that projects into deeper brain sites and further into the brainstem and thalamus (the sensory-system “hub” of our brains). From the brainstem and thalamus, information carrying pain sensations from the body is transmitted to other areas of the brain, such as limbic areas. 

For most people, migraines arise from a complex genetic disor der with susceptibility that depends on specific genetic variants. The details of these genetic predispositions for migraine disorders are not entirely understood. What we do know is that, with migraines, cere brovascular (the blood vessels in the brain) and meningeal (the membrane that protects the brain and houses a vast network of nerves) pain stimulation may predominate. 

Traditional theories of the cause of migraines fall into two cat egories: vasogenic (blood-supply based) and neurogenic (nerve based). With vasogenic migraines, the theory is that intracranial vasoconstriction (reactionary narrowing of the blood vessels within the brain resulting in a change of blood flow) is responsible for the aura portion of migraines, and the subsequent headache results from rebound blood-vessel dilation, distention of vessels within the brain, and inflammation of the sensory neurons that line these 

hyperexcitation of the neurons moves across the brain’s cortex after chemical or mechanical disturbances. This hyperexcitation then causes a series of reactions that result in meningeal irritation and changes in the intracranial blood flow, precipitating migraines. 

Tension-Type Headaches 

Tension-type headaches are the least understood in headache pathology. These are the most common of primary headache disor ders, yet TTHs continue to defy a single pathophysiological expla nation. The importance of muscular and myofascial structures is acknowledged in many, but not all, cases of this type of headache. Given the focus on muscular and myofascial input in TTH, it is helpful to understand that myofascial stretching with yoga can help in this condition, as discussed below. 

Cluster Headaches 

Historically, little was known about the cause of cluster headaches. New speculation suggests that cluster headaches are caused by pathophysiological events that activate the trigeminal-vascular sys tem. (The trigeminal, cranial nerve V, is the largest cranial nerve, with projections through the face, head, and neck.) In this syndrome, pain is manifested in the first and second trigeminal division, causing sympathetic activation (usually represented as sweating of the forehead and face), sympathetic dysfunction (Horner’s syndrome, which is a droopy eyelid and constricted pupil on one side), and parasympathetic activation (tearing and nasal congestion). This array of symptoms is thought to be due to abnor malities at the point where the ophthalmic and maxillary trigeminal nerves converge. 

Medical Management of Headaches 

Headaches have traditionally been managed with medications. With that in mind, it is important to note that only half of people with headache disorders actually obtain relief with medications. Furthermore, those treated with medications often discontinue their treatment because of unwanted side-effects. Even worse, over use of medications in an attempt to manage headaches can often lead to a phenomenon called “medication-overuse headaches,” in which the quality and duration of headaches actually worsen. Another unfortunate paradox of headache management is that discontinuing medications after regular and frequent use may lead to rebound headaches. Because of these poor outcomes, side-effects, and sequelae due to medication use, complementary and alternative medicine has become common practice in headache management.2 

Yoga Therapy for Headache Management 

Yoga has been reported as a safe and cost-effective intervention for managing headache pain.3 A growing body of evidence supports the belief that yoga benefits both physical and psychosocial health through the mechanisms of downregulation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis.4 As a result, yoga can play a vital role in reducing sympathetic activity, increasing parasympathetic activity, improving the quality of life, and decreasing pain levels when managing headaches.5 

To support headache sufferers with yoga therapy, the practi tioner must start with a specific and detailed client history. This his tory needs to contain information about the client’s headaches, including frequency; duration; character; severity; location; quality; and the factors that trigger, aggravate, or alleviate the symptoms. With yoga therapy, a significant change in the nervous system demonstrating improved vagal tone and reduced sympathetic (fight or-flight) activity has been observed.6 This further resulted in improved cardiac autonomic balance. These findings indicate that adjuvant yoga therapy may be effective for people with migraines. 

When recording the history, it is important to ask about specific lifestyle habits, such as diet, caffeine use, sleep habits, work, or personal stress. Any contributing factors should also be uncovered during history taking such as associated sleep disorders, depression, anxiety, and/or other underlying medical disorders. If any contributing factors are revealed at this time, consider referral to a qualified medical professional for further workup and evaluation of these underlying conditions. Be sure to also ask about relevant family history because, as mentioned above, some individuals have a genetic 

Science for the Yoga Therapist 

vessels, may help in reducing migraine attacks.8 NO plays a key role in regulating brain metabolism, cerebral circulation, and blood vessel function. It is one of the factors for modulating cerebral blood flow in response to changes in oxygen and carbon dioxide levels within the blood vessels. Repeated exercises that increase NO and sustain its levels within the blood have been demonstrated to decrease migraine frequency, severity, and duration.9 Thus, pranaya ma may be particularly beneficial for headaches, and in particular, for migraines, because studies have shown the improvement of NO levels due to pranayama practices.8 

Breathwork 

The conscious breathing of pranayama is known to have a calming effect on the nervous system and emotions, such as reduced fear and anxiety.10 Pranayama may further help to diminish tensions that have accumulated around the forehead, temples, neck, and shoul ders.11 Studies have shown that pranayama can lead to more oxygen delivery to the whole body, including to the heart and brain.12 As a lowered blood oxygen level is one of the risk factors of migraine, learning to efficiently use oxygen with pranayama can be a potential solution. Pranayama has been offered as a method for balancing the autonomic nervous system and has a powerful influence on stress release, as stress is a significant risk factor for vascular dysfunctions.11 

I will not be so bold as to offer specific pranayama techniques for relief of migraines; the choices of technique will largely depend on the individual and on your history-taking, as stated above. I will note, however, that one specific study mentioned using kapalabhati (skull-shining breath or breath of fire) and demonstrated improve ment in NO levels and lessening of migraine severity with this technique.8 

Mechanical Stretches of Muscles and Fascia 

If done correctly, yoga can significantly release tensions accumulat ed around the areas of pain (often the forehead, temples, neck, and/or shoulders).9 For headaches specifically, yoga postures can tar get stretching of the neck, shoulder, and back muscles, followed by relaxation. Teaching correct posture (ergonomically speaking) and the stretching of cervical spine muscles can also be helpful, especial ly for TTH.13,14 As tight muscles can trigger headaches, yoga could potentially assist in alleviating symptoms of TTH. 

predisposition for migraines.7 Above all, as always, yoga therapists must remember to stay within their scope of practice and refer patients to qualified medical professionals for support with any issues that will not or should not be addressed by yoga therapy. 

The Role of Nitric Oxide 

It is thought that the practice of yoga may increase nitric oxide (NO) levels in the cardiovascular system and even in specific parts of the body (see “Nitric Oxide & Mouth Breathing: Physiology You Want to Understand,” by Heidi Dickerson, DDS, at www.lviglobal.com/wp-content/uploads/2017/06/NitricOxideMouthBreathing.pdf ). 

The theory behind this is that NO, a crucial and global signal ing chemical made in and excreted from the lining of the blood. Studies also demonstrate that specific stretches and manual therapies for the neck can be helpful in headache relief.15 

Again, I will not opine upon exact postures to practice with clients, as every individual’s anatomy will be different, and again, your history-taking may reveal contraindications to head and neck stretching to end ranges. As always, working with clients one to one to determine appropriate practices will be the key to efficacy and safety.

Yoga as Exercise 

The use of exercise as a prophylactic treatment for headaches has been researched and is recommended by clinicians more regularly for headache prevention. Studies have shown that exercise has a therapeutic effect on migraines by increasing blood levels of endor phins and pain-relieving hormones. However, it is important to note that intense exercise also paradoxically triggers increased calcitonin gene-related peptide (CGRP) and lactate levels, which may be a sign of increased inflammation,14 and thus sustain an environment to induce headaches. Therefore, although exercise may be indicated to increase pain-relieving hormones, a balance must be struck regard ing the intensity and duration of exercise. 

This is where yoga may play a particularly helpful role in headache relief. Because yogic postures can be performed slowly and mindfully, along with breathing and relaxation exercises and pranayama, this type of physical activity may prevent an increase in CGRP and lactate levels. Thus, yoga, as a measured form of exercise with individualized pacing, may be particularly well-suited for headache prevention, with performance causing the release of pain relieving hormones and neurotransmitters while avoiding the release of potentially pain-inducing substances. 

Meditation 

Meditation is known to reduce headache duration and disability while increasing self-efficacy and mindfulness. Particularly in pri mary headaches, meditation has been found to decrease headache intensity and frequency with no associated side-effects.16 Moreover, meditation has been shown to significantly improve self-efficacy,

which is the ability to motivate, follow through, and complete tasks unaided. When self-efficacy is elevated, people have a better quality of life. The studies are varied regarding meditation techniques; cur rent guidance is simply to incorporate mindfulness-based exercises into yoga therapy for headaches.17 Similarly, positive effects of headache reduction have been found in other relaxation exercises, such as Yoga Nidra and guided relaxation. 

A Case for Yoga Nidra 

Although there is currently no specific published research 

Yoga nidra meditation has been associated with increased endogenous dopamine release in the brain.21 (Dopamine is current ly seen as a neurotransmitter closely tied to our ability to think, plan, act, and experience pleasure.) As practitioners ourselves, we know that Yoga Nidra can cause us to feel ease and pleasure by decreasing our overall feelings of stress. And if generalized stress reduction can decrease headaches symptoms in clients, it is always worth a try. 

Yoga Therapy—A Frontier in Headache Treatment? 

As yoga therapists have long known, a sustained and continued yoga practice can contribute to a state of calm alertness and an increase in parasympathetic activation.22 This tones the stress-response systems and releases hormones that improve feelings of happiness and well being. In addition, yoga asana also improves physical and mental processes and helps relieve stress and anxiety, factors known to intensify migraine onset, severity, and frequency. 

The system of yoga is a powerful tool that helps to build a com prehensive skillset of synergistic processes to improve function and quality of life. Within these processes, headache symptoms can be alleviated, lessened, or prevented. Yogic practices facilitate bidirec tional feedback and integration between high- and low-level brain networks. This makes yoga a unique therapy for balancing the auto nomic nervous system and influencing physical, psychological, and stress-related disorders, such as headaches. Introducing yogic tech niques to clients with chronic conditions of all kinds could mean symptom relief, and helping them to keep an open mind could be life-changing. YTT 

 

References 

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  2. Sang-Dol, K. (2015). Effects of yoga exercises for headaches: A systematic review of randomized controlled trials. Journal of Physical Therapy Science, 27(7), 2377–2380. https:// doi:10.1589/jpts.27.2377 
  3. Brummer, M. (2005). Yoga and ayurveda for headaches and migraines. Positive Health Online: Integrated Medicine for the 21st Century, 110, 45–48. Retrieved from www.positivehealth.com/article/yoga/yoga-and-ayurveda-for-headaches-and migraines 
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  12. https://doi:10.1016/j.explore.2011.10.004 Amin, F. M., Aristeidou, S., Baraldi, C., Czapinska-Ciepiela, E. K., Ariadni, D. D., Di Lenola, D., . . . European Headache Federation School of Advanced Studies. (2018). The association between migraine and physical exercise. Journal of Headache Pain, 19, 83. https://doi.org/10.1186/s10194-018-0902-y 15. Castien, R., & De Hertogh, W. (2019). A neuroscience perspective of physical treatment of headache and neck pain. Frontiers in Neurology, 10, 276. https://doi:10.3389/fneur.2019.00276 
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