professional yoga therapy medical therapeutic yoga for the ...3.differentiate between the types of...
TRANSCRIPT
1
Modules 6 amp 7
Achieving Structural Balance Biomechanics Neurophysiology amp Joint Function in Yoga Posture
Module SixApplied Biomechanics in Asana for
Stabilization Motor Control and SupportGinger Garner PT MPT ATC PYT DPT-C
ObjectivesAfter completing Module 6 you should be able to1 Explain how joint stabilization requisites are used in the
biopsychosocial model of integrative medicine to evolve yoga for
clinical use and efficacy
2 List the evidence-based precepts for achieving integrative lumbopelvic stabilization in medical and wellness-based yoga
programs3 Differentiate between the types of yoga postures in the post-graduate
professional yoga therapy system that facilitate safe modification and allow for medical adaptation in both high and low functioning patient populations
4 Apply the latest research in lumbopelvic stabilization and
neurophysiology to allow yoga postures to be prescribed as rehabilitation
copy 2001-2013 Ginger Garner All rights reserved
2
Professional Yoga Therapy
Samkhya Philosophy (East) and Quantum Physics (West)
copy 2001-2013 Ginger Garner All rights reserved
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexesbull Tactile sensebull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy 2001-2013 Ginger Garner All rights reserved
3
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy 2001-2013 Ginger Garner All rights reserved
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
4
Precepts Safety amp Efficacyin Prenatal Practice
Precept 1 Use of the Biopsychosocial Model
Precept 2 Breath before the Pose
Teach A-D Breath before TATD Breath
Precept 3 TATD Breath for Stability
Precept 4 Stability before Mobility
Precept 7 Spine receives priority
Precept 12 No weight bearing inversions are taught
Precept 13 Practice joint preservation and protect small ampor vulnerable joints hands feet pelvis
5
Establishing Structural Balance
1 Joint Structure amp Function
2 Integrated Model of Joint Function
3 Requisites for Joint Stabilization
4 Psychoneuroendocrinology
Sports Illustrated - Robert Beck copy photo
Integrated Model of Joint Function
1 FORM CLOSURE(Snijders et al 1993 1995 Norkin and Levangie 2005)
2 FORCE CLOSURE(Snijders 1993 Richardson et al 1999
Carolan amp Catarelli 1992)
3 MOTOR CONTROL (neural patterning) (Damen et al 2002 Hides
1994 Hungerford 2004 Hodges and Richardson 1996 Kankaanpaa et al 1998
Lee 2004 Lee and Lee 2004 Leiononen et
al 2000)
4 AWARENESS AND RESPONSE TO EMOTIONAL FACTORS(Holstege et al 1996 Ewing and Ewing
2009 Neil et al 2010)
FOUR COMPONENTS OF LUMBOPELVIC STABILITY
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
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14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
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LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
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21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
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Thoracic Diaphragm
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22
Respiratory Diaphragm
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Pelvic Diaphragm
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23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
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copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
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24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
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Transversalis Fascia
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25
Peritoneum
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Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
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Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
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30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
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33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
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Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
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Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
2
Professional Yoga Therapy
Samkhya Philosophy (East) and Quantum Physics (West)
copy 2001-2013 Ginger Garner All rights reserved
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexesbull Tactile sensebull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy 2001-2013 Ginger Garner All rights reserved
3
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy 2001-2013 Ginger Garner All rights reserved
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
4
Precepts Safety amp Efficacyin Prenatal Practice
Precept 1 Use of the Biopsychosocial Model
Precept 2 Breath before the Pose
Teach A-D Breath before TATD Breath
Precept 3 TATD Breath for Stability
Precept 4 Stability before Mobility
Precept 7 Spine receives priority
Precept 12 No weight bearing inversions are taught
Precept 13 Practice joint preservation and protect small ampor vulnerable joints hands feet pelvis
5
Establishing Structural Balance
1 Joint Structure amp Function
2 Integrated Model of Joint Function
3 Requisites for Joint Stabilization
4 Psychoneuroendocrinology
Sports Illustrated - Robert Beck copy photo
Integrated Model of Joint Function
1 FORM CLOSURE(Snijders et al 1993 1995 Norkin and Levangie 2005)
2 FORCE CLOSURE(Snijders 1993 Richardson et al 1999
Carolan amp Catarelli 1992)
3 MOTOR CONTROL (neural patterning) (Damen et al 2002 Hides
1994 Hungerford 2004 Hodges and Richardson 1996 Kankaanpaa et al 1998
Lee 2004 Lee and Lee 2004 Leiononen et
al 2000)
4 AWARENESS AND RESPONSE TO EMOTIONAL FACTORS(Holstege et al 1996 Ewing and Ewing
2009 Neil et al 2010)
FOUR COMPONENTS OF LUMBOPELVIC STABILITY
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
3
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy 2001-2013 Ginger Garner All rights reserved
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
4
Precepts Safety amp Efficacyin Prenatal Practice
Precept 1 Use of the Biopsychosocial Model
Precept 2 Breath before the Pose
Teach A-D Breath before TATD Breath
Precept 3 TATD Breath for Stability
Precept 4 Stability before Mobility
Precept 7 Spine receives priority
Precept 12 No weight bearing inversions are taught
Precept 13 Practice joint preservation and protect small ampor vulnerable joints hands feet pelvis
5
Establishing Structural Balance
1 Joint Structure amp Function
2 Integrated Model of Joint Function
3 Requisites for Joint Stabilization
4 Psychoneuroendocrinology
Sports Illustrated - Robert Beck copy photo
Integrated Model of Joint Function
1 FORM CLOSURE(Snijders et al 1993 1995 Norkin and Levangie 2005)
2 FORCE CLOSURE(Snijders 1993 Richardson et al 1999
Carolan amp Catarelli 1992)
3 MOTOR CONTROL (neural patterning) (Damen et al 2002 Hides
1994 Hungerford 2004 Hodges and Richardson 1996 Kankaanpaa et al 1998
Lee 2004 Lee and Lee 2004 Leiononen et
al 2000)
4 AWARENESS AND RESPONSE TO EMOTIONAL FACTORS(Holstege et al 1996 Ewing and Ewing
2009 Neil et al 2010)
FOUR COMPONENTS OF LUMBOPELVIC STABILITY
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
4
Precepts Safety amp Efficacyin Prenatal Practice
Precept 1 Use of the Biopsychosocial Model
Precept 2 Breath before the Pose
Teach A-D Breath before TATD Breath
Precept 3 TATD Breath for Stability
Precept 4 Stability before Mobility
Precept 7 Spine receives priority
Precept 12 No weight bearing inversions are taught
Precept 13 Practice joint preservation and protect small ampor vulnerable joints hands feet pelvis
5
Establishing Structural Balance
1 Joint Structure amp Function
2 Integrated Model of Joint Function
3 Requisites for Joint Stabilization
4 Psychoneuroendocrinology
Sports Illustrated - Robert Beck copy photo
Integrated Model of Joint Function
1 FORM CLOSURE(Snijders et al 1993 1995 Norkin and Levangie 2005)
2 FORCE CLOSURE(Snijders 1993 Richardson et al 1999
Carolan amp Catarelli 1992)
3 MOTOR CONTROL (neural patterning) (Damen et al 2002 Hides
1994 Hungerford 2004 Hodges and Richardson 1996 Kankaanpaa et al 1998
Lee 2004 Lee and Lee 2004 Leiononen et
al 2000)
4 AWARENESS AND RESPONSE TO EMOTIONAL FACTORS(Holstege et al 1996 Ewing and Ewing
2009 Neil et al 2010)
FOUR COMPONENTS OF LUMBOPELVIC STABILITY
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
5
Establishing Structural Balance
1 Joint Structure amp Function
2 Integrated Model of Joint Function
3 Requisites for Joint Stabilization
4 Psychoneuroendocrinology
Sports Illustrated - Robert Beck copy photo
Integrated Model of Joint Function
1 FORM CLOSURE(Snijders et al 1993 1995 Norkin and Levangie 2005)
2 FORCE CLOSURE(Snijders 1993 Richardson et al 1999
Carolan amp Catarelli 1992)
3 MOTOR CONTROL (neural patterning) (Damen et al 2002 Hides
1994 Hungerford 2004 Hodges and Richardson 1996 Kankaanpaa et al 1998
Lee 2004 Lee and Lee 2004 Leiononen et
al 2000)
4 AWARENESS AND RESPONSE TO EMOTIONAL FACTORS(Holstege et al 1996 Ewing and Ewing
2009 Neil et al 2010)
FOUR COMPONENTS OF LUMBOPELVIC STABILITY
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
6
General Joint Stabilization Requisites During Exercise
1 Facilitate co-contraction
2 Slow controlled closed kinetic chain activities
3 Pay attention to the biomechanics of joint position
4 Position joints
5 Accommodate unstable environments
6 Focus on precision and control
7 Use low-load force levels and multi-joint synergistic training
Willson JD Dougherty CP Ireland ML Davis IM Core stability and its relationship to lower extremity function and injury J Am Acad Orthop Surg 200513(5)316-325
Hodges PW Richardson CA Inefficient muscular stabilization of the lumbar spine associated with low back pain a motor control evaluation of transversus abdominus Spine 199621(22)2640-2650
The Future of Neurologic Rehabilitation Translating the Latest Research into
Clinical Application
Historical Support for LP Stability
bull Spinal Stability - Cylinder ndash Primary stabilizers amp syndergistshellip dynamic stabilization of the lumbar spine and sacro-iliac joint (Hides et al 1996 Hodges and Richardson 1996 Hodges et al 1997 Sapsford et al 2001)
bull Spinal Instability - lsquosignificant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits which results in pain and disability (Panjabi 1992)
bull On stabilizationhellipbull Panjabi (1992)
bull Lee (2005)
bull Lee (2005)
bull Lee (2005 Vleeming et al 1990 Lee amp Vleeming 1998 Lee 2001)
bull Hodges and Cholewicki (2007)
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
7
Form Closure Spine
Form and Force ClosurePelvic Floor Anatomy
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
8
Form ClosureSacroiliac Joint Anatomy
Sacroiliac Joint Physiology
Shock absorbency counteracting compressive forces during gait and
single leg stance and by integrated model of joint function
bull 3 axes of rotation (x y z)
bull Translation
bull NutationCounternutation
bull Triplanar movement = torsion
Goode A et al Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man amp Manip Ther 200816(1)25ndash38
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
9
copy 2013 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2011 All rights reserved
Support for Yoga PosturesForm Closure
FORM CLOSURE
Internal Support
Lumbopelvic amp Scapulohumeral stabilization
Co-contraction
Proprioceptive awarenessSpinal neutral
External Support (in absence of internal
support)
Blocks bolsters wedges blankets
Straps ropes
Walls chairs
PartnerPrecept 11
In order for an asana to be internally supported there must be implementation of and initiation of co-
contraction at multiple joints
Force ClosureNomenclature TATD Breath
4 PART ldquoCYLINDERrdquo (RICHARDSON) OR ldquoCANISTERrdquo (LEE)
1 ANATOMICAL APPROXIMATIONBiomechanical - TvA PFM Multifidi Respiratory diaphragm (+ flexible fascia + strong synergists)
2 SCIENCE OF ACTION Physiological
3 SAFETYClinical Efficacy
Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson 1997 Cholewicki amp McGill 1996 Cholewicki
amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodges and Gandevia 2000 Hodges et al 2003 McCandless 1975
Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
10
0 6
3
Beginner Force Coupling amp Postural Awareness in a Small Neutral Zone
Postural Awareness ndash in all planes (seated SL standing etc)
bull ldquo0-6-3rdquo Methodbull 0 = Posterior Pelvic Tilt
bull 6 = Anterior Pelvic Tilt
bull 3 = Spinal Neutral
bull Pelvic Clock
Stability + Mobility = Controlled Flexibility
bull TATD Breath
bull Control in small neutral zone
bull Single plane to multi-plane
bull Increase degrees of freedom in direct proportion to the control available in the growing neutral zone
IntegrativeConventional
Functional Assessment amp Management of Low
Back Pain
15 MEASURES OF ASSESSMENT through MTY
1 CENTRALIZATION OF SYMPTOMS amp SPINAL MOBILITY
2 RADICULAR PAIN NEURAL TENSION amp FUNCTIONAL MOBILITY (2)
3 JOINT FUNCTION amp PROPRIOCEPTION
4 POSTURAL AWARENESS amp CONTROL
5 TVA ISOLATION AND ENDURANCE
6 MULTIFIDI FUNCTION
7 PELVIC FLOOR CONTROL
8 ENDURANCE ASSESSMENTS (5)
9 HIP MOBILITY amp JOINT INTEGRITY
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
11
Motor Control amp Neural Patterning in Yoga Postures
In order of importance for biomechanicalstructural
stabilization
1 Lumbopelvic Stabilization (PROXIMAL)
2 Scapulothoracic Stabilization (DISTAL)
Precepts 4 7 and 11
PYT holds lumbopelvic stabilization using the ldquotrunk cylinderrdquo approach as its foremost intention and most important precept (behind the breath) in
its definition of creating and maintaining a stable safe pose (asana)
TA Isolation and Palpation
bull TA Isolation inoutside of spinal neutral
bull Mountain
bull Seated
bull Supine hook lying
bull Sidelying
bull 4 point
bull Prone
bull Positive test ndash Clinician palpates for TA contraction and maintenance
bull Positive test is indicated if patient unable to maintain position (no pelvic translation) statically or dynamically (when armleg AROM introduced)
Palpate with
the index and middle fingertips
just medial
to the ASIS
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
12
Lumbopelvic Integrity RCTrsquos support PFM
bull Cochrane reviews on
RCTrsquos (Level 1 Grade A) from 2008-2011 supports
that PFM training is
effective in tx of
bull SUI
bull POP
bull With proper
supervised instruction
ONLY
Sapsford Ruth amp Hodges Paul The effect of abdominal and pelvic floor muscle activation on urine flow in women International Urogynecology Journal Springer London 0937-3462 Medicine Boslash K and Braeligken IH Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse Pelvic Floor Disorders 2010 Section VI Part 6 531-537 DOI 101007978-88-470-1542-5_73
bullPrecept 2 -
Postures unless restorative
should use TATD breath
bullPrecept 3 -
Emphasizes breath mastery
before postures
copy 2001-2013 Ginger Garner All rights reserved
Scapulothoracic Stabilization amp Injury
Prevention
bull Force Coupling ndash 17 muscles of ST stabilization
bull Decreased RTC EMG amp cadaver dissectionremoval of RTC reveal deltoid contribution to humeral head superior translation during early abduction leading to impingement
Page P Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J sports phys ther 2011 march 6(1) 51ndash58copy 2001-2013 Ginger Garner All rights reserved
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
13
Concomitant Force Coupling
PYT Posture Arm Spiral amp Downward Facing Dog Prep Pose
bull STSH amp LP RhythmStab
bull Postural alignment
bull Spinal Neutral
bull TATD breath
bull Serratus Anterior
bull Lower Trapezius
bull RTC Health
bull Myofascial release
bull Neural mobilization
Downward Dog Preparation
Left ndash starting position Right ndash final arm spiral
copy 2001-2013 Ginger Garner All rights reserved
Modifications
Block supported thumb release ndashfrom four point or against wall or on chair
Modified arm spiral ndash from seated or supine
copy 2001-2013 Ginger Garner All rights reserved
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
14
LP amp ST StabilityCatCow in Four Point
Note thumb positioning on blocks
Top ndash cat Bottom - cow
copy 2001-2013 Ginger Garner All rights reserved
LP and ST StabilityldquoShoulder Openerrdquo
Shoulder Opener Sequence - SH Stabilization LP Stabilization
TATD breath Spinal Neutral Osteokinematic ROM requiring Arthrokinematic ROM MFR Neural Mobilization
copy 2001-2013 Ginger Garner All rights reserved
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
15
Lab Application Biomechanical Analysis
Four Step Process
ldquoHelicopter Analysisrdquo ndash all planes
Conceptual Model Sheath Check
Utilize multiple methods of cuing
1 Centering
2 LP Stabilization amp Postural ControlAlignment -
3 ST Stabilization
4 Lower Quarter Alignment and Protection
Extended Side Angle
copy 2001-2013 Ginger Garner All rights reserved
Lab Application 2Bridge amp Variations
bull Endurance Hip Extensors
bull Supine hook lying Pt raises pelvis from table into a ldquobridgerdquo position Position is held and timed until the position can no longer be maintained
bull Advanced clinical management
bull MTY Dissociation of gluts from hamstrings
copy 2001-2013 Ginger Garner All rights reserved
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
16
Mobilization
Safe instruction requires knowledge of the open and closed packed position of each joint in the body (Module 7)
Arthrokinematics vs Osteokinematics (Module 10)
Neurovascular Mobility amp Neurophysiology (Module 7)
Affects of posture on joint in points of the Pentagon (Module 8)
Precept 9 Stability is given priority over mobility in order of
proximal to distal attention
copy 2001-2013 Ginger Garner All rights reserved
Enhancing Biomedical Rehab PracticeSupportive Clinical Environment
Yoga Posture amp Breath Prescription (M8)
bull Autogenic
Trainingbiofeedback
bull Algorithm Application
bull Skill set ndash manual and
mobilization with movement (MWM) during
yoga
bull Kinesthetic Interventions
bull Lifestyle counseling
bull Relational
bull Self-reflection activitiescopy 2001-2013 Ginger Garner All rights reserved
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
17
Resources
bull Graduate Level Studies Pro bono work in educational curriculum development wwwprofessionalyogatherapyorg
bull US
bull Canada
bull Europe
bull Post-graduate studiesProfessional Yoga Therapist Certification wwwprofessionalyogatherapyorg
bull Next step Module 8 (on-site lab intensive)
bull wwwgingergarnercom - Videos downloads pubs on yoga Rx
bull The Integrated Model of Joint Function (Diane Lee)
bull Biomechanical Precepts Define 21st Century Yoga (Ginger Garner)
copy 2001-2013 Ginger Garner All rights reserved
Module SevenAchieving Structural Balance
Neurophysiology Stability amp Joint Function in Practice
Ginger Garner PT MPT ATC PYT DPT-C
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
18
Objectives
After completing Module 7 you should be able to1 Review the latest research to apply the professional yoga therapy
diagnostic algorithm for evaluation and prescription in medical therapeutic yoga and how it impacts functional progression in objective goal setting
2 Explain the neurophysiology of safe medical therapeutic yoga practice as it relates to myofascial release and neural mobilization
3 List the guidelines precautions and contraindications for performing soft tissue mobilization andor manual therapy within the context of yoga postures
4 Identify how myofascial restriction and neural mobilization can be addressed through the practice and sequencing of yoga postures
5 Understand the ramifications of kinetic chain and joint positions in medical therapeutic yoga progression and prescription for affecting functional
neural patterning and balance across the lifespan
copy2001-2015 Ginger Garner
7 Physiological Concepts 1-3
1 Kinesthetic awareness and the
senses
bull NeurofeedbackModulation of Nociceptive Input
bull Reflexes
bull Tactile sense
bull Vestibular sense
bull Visual sense
2 Respiration
bull A-D Breathbull TATD Breath
3 Stabilization and Neural Patterning
(neuromuscular and musculoskeletal)
bull General jointbull Lumbopelvic
bull Scapulothoracic
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
19
7 Physiological Concepts 4-7
4Mobilization
bull General joint
bull Neural
bull MyofascialRestriction and Release
5 Balance
bull Static
bull Dynamic
6 Support
bull Internal intrinsic
bull External extrinsic
7 Stress Management
bull Relaxation
bull Meditation
copy2001-2015 Ginger Garner
Neurophysiology of Yoga Addressing Movement in Asana
Behavioral organization
Sensori-motor connection
Mindbody interaction
Allostasis
Precept Review (4)
After static and dynamic functional stability have been established static
and dynamic mobility can be addressed
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
20
Behavioral Organization
copy2001-2015 Ginger Garner
Horizontal Diaphragms
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
21
ldquoDense irregular connective tissue sheets
IE (Schleip et al 2005)
Aponeuroses
Joint capsules
Muscular envelopes like the
endo- peri- and epimysium
Fascia traditionally seen as passive (transmitter)
Evidence base supports active role
Fascia
copy2001-2015 Ginger Garner
Thoracic Diaphragm
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
22
Respiratory Diaphragm
copy2001-2015 Ginger Garner
Pelvic Diaphragm
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
23
Muscles are Important but how about Fascia
Superficial fascia lying beside the body from which it came Gil
Hedley 2005 httpwwwgilhedleycom
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Embryology
Fascia of the diaphragm
bull Endothoracic (pharyngeal retrovisceral prevertebral esophageal sphincters)
bull TransversalisVisceralPeritoneal
bull Endopelvic
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
24
EndothoracicFascia
Endothoracic fascia by Egmason - Own work Licensed under CC BY-SA 40 via Wikimedia Commons -
httpscommonswikimediaorgwikiFileEndothoracic_fasciasvgmediaFileEndothoracic_fasciasvg
copy2001-2015 Ginger Garner All rights reserved
copy2001-2015 Ginger Garner
Transversalis Fascia
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
25
Peritoneum
copy2001-2015 Ginger Garner
Schleip 2003 Schleip 2005 van den Berg and Cabri1999 Manuel et al 2008 Kruger 1997 Rolf 1977
WillardFH VleemingA SchuenkeMD DanneelsL SchleipR The
thoracolumbar fascia anatomy function and clinical considerations JAnat 2012
221 6 507-536 Blackwell Publishing Ltd
Living Fascia
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
26
Figure 1 Normal urethral support
Fatton B et al (2014) Stress urinary incontinence and LUTS in womenmdasheffects on sexual function
Nat Rev Urol doi101038nrurol2014205
Support
Provision of skin integrity (Stecco et al 2012
Contribution of muscular contraction via smooth muscle fiber instrusion in fascia (Staubesand and Li 1996)
Spontaneous ligament contraction in lumbodorsal fascia (Yahia et al 1993)
Force generation and transmission in TL fascia (Willard et al 2012 Barker et al 2010)
Fascial limit of lumbar spinal mobility (Schleip et al 2005 Barker et al 2004)
Venous return (Bordoni and Zanier 2013)
Contribution to nociception (Moseley 2008)
Tension transmission between the epimysium = contribution to force generation (Willard et al 2012 Barker et al 2010)
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
27
The Thoracolumbar Fascia Anatomy Function and Clinical Considerations
copyJournal of AnatomyVolume 221 Issue 6 pages 507-536 27 MAY 2012 DOI 101111j1469-7580201201511xhttponlinelibrarywileycomdoi101111j1469-7580201201511xfullf13
Mechanoreception
Drake 2009 Willard et al 2012
Golgi tendon organs amp Ruffini endings
slow adapting respond to tension
Pacinian corpuscles amp Meissnerrsquos corpuscles
rapidly adapting respond to vibration
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
28
Skin Interruptions and AdhesionsPain resulting from surgical incisions or hernias (Moore 2009 Theodoros et al
2001 Cimen et al 2004)
Potential for long term impact
Adhesions in gt 90 of postoperative patients following major abdominal surgery
55-100 of the women undergoing pelvic surgery
(Parker et al 2001) High relative risk of adhesion related problems after open lower abdominal surgery ldquoImproved adhesion prevention strategies must be consideredrdquo
Postoperative peritoneal adhesions Complication following gynecological and general abdominal surgery
Myofascial restriction resultant Most common consequences (4)
copy2001-2015 Ginger Garner
ConclusionsBehavioral Organization
bull IFhellipTHEN THEORY
(Schleip 2003 Rolf 1977 Barnes 1997 Pichinger 1991)
Loukas et al 2008 Stecoo et al 2011 Willard et al 2012)
bull Problems in
diaphragmatic fasica could implicatehellip
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
29
Central Diaphragm Effect
copy2001-2015 Ginger Garner
Sensori-Motor Connection
Since fascia has both nociceptive and proprioceptive
innervation what are the
potential sensori-motor implications
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
30
Affects local
blood supply and tissue
viscosity
Tissue response
Palpable response felt by therapist
Myofascial or
soft tissue
manipulation within an
asana
Interfascial Circulation Loop
Mitchell amp Schmidt 1977 Rolf 1977 Barnes 1997 Pichinger 1991 Scleip 2003 Schleip 2005
copy2001-2015 Ginger Garner
Fascial Reception
copyGinger Garner Living Well Inc
TYPE LOCATION RESPONSE
I Myotendinous junctions
Muscular contraction and strong stretch Effectmechanoreception ldquotonus decrease in related striated motor fibersrdquo
II Pacini receptors and Ruffini receptors
Pacini Rapid pressure changes and vibrations proprioceptive feedback for affecting movement strategies
Ruffini lateral stretch sustained pressure Effect autonomic inhibit SNS
III amp IV Intersitial Rapid and sustained pressure
Effect Vasodilation and plasma
extraversion mechanoreception
thermoception nociception chemoception
Adapted from Schleip 2003copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
31
Mind-Body Interaction
bull What is the role of MTY in MFR
Conventional Treatment often addresses Scar mobilization
Myofascial release and trigger point therapy
Gradual release of the overlying fascia with manual techniques
copy2001-2015 Ginger Garner
Allostasis
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
32
Cognitive Activation Theory
Stress amp stimuli Somatic Nervous System affected by
Poor breathing habits Damaged anatomy affected by
Environmental toxins Poor lifestyle choices Illness
Stress experience Anxiety states General stress response alarm in
a homeostatic system producing neurophysiological activation to increase arousal
Fight flight or freeze ndashnecessary
Sustained states ndashunnecessary leading to O2 amp CO2 imbalance ndash altered ventilation states (hypo amp hyper
Experience of the stress responsebull Multi-system pathophysiological
processesbull Conceptual model
derangementbull GIbull MSbull NMbull Mindbody -
Psychoneuroimmunologicaland endocrine function emotional social intellectual
Resulting in Psychological defense ndash distortion of stimulus expectancies which sets up coping abilities
Ursin H The development of a Cognitive Activation Theory of Stress From limbic structures to behavioral medicine Scandinavian Journal of Psychology Vol 50 Issue 6 pages 639-644 December 2009
copy2001-2015 Ginger Garner All rights reserved
Allostatic Load Flight Fight (or Freeze)
copy2001-2015 Ginger Garner All rights reserved
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
33
What Happens In Vagus Stays in Vagus
Dhanunjaya Lakkireddy MD Donita Atkins RN Jayasree Pillarisetti MD Kay Ryschon MS Sudharani Bommana MPHIL Jeanne Drisko MD
Subbareddy Vanga MBBS MS Buddhadeb Dawn Effect of Yoga on Arrhythmia Burden Anxiety Depression and Quality of Life in Paroxysmal Atrial FibrillationThe YOGA My Heart Study J Am Coll Cardiol 201361(11)1177-1182
copy2001-2015 Ginger Garner All rights reserved
Phylogenetic Origins
Porges_The Science of Compassion_Lecture_Origins Measures amp Interventions_ccarestandfordedu_Telluride 2012_ copy2001-2015 Ginger Garner All rights reserved
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
34
From Theory to Practice MTY Intervention
Address affected tissues that are short andor tight within a pose or breath
Note the primary shortened myofascia
Note both the agonist and the antagonists of the related joint
Note tissues that have higher density mechano-receptors (Schleip)
Slow progression through postures
Breaking down postures and breath techniques into multiple complex components for MFR
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
Practical Guidelines
1 Provide skin on skin intervention
2 Facilitate tonus decrease and reduce sympathetic tone
3 Attend to mask of face vitals skin temp and any histamine response and response to tx
4 Hold or apply treatment 120-300 seconds (Ajimsha et al 2014)
5 Consider high grade joint mobilizations and home programs in certain conditions (Jacobs amp Sciascia 2011)
6 Consider therapist and self-release (IHP)
Photo rutgersedu
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
35
Determine level of touch by patient response
Get constant feedback and refine touch and pressure PRN (Schleiprsquos ldquoMicromovement treatmentrdquo)
Ask and allow for deepening of feeling
or proprioception in a pose
Increased sensitivity = Slow pace of yoga practice
Facilitate donrsquot manipulate Functional carry over ndash ask the
patient to relate their movements to
everyday activities and their physical and social meanings
Restorative Cobblerrsquos Pose
Progression
copy2001-2015 Ginger Garner
Lateral Raphe
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
36
Diaphragmatic Release
copyGinger Garner Living Well Inccopy2001-2015 Ginger Garner
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
37
Neurophysiological amp Psychoneurological Rehabilitation
Neural Mobilization (NM) ndash Butlerrsquos (1991) new frontier Born from manual therapy physiotherapists
Derived from
Reexamination of nervous system
Clinical neurobiomechanics working definition
NM has immense therapeutic application in the field of medical
therapeutic yoga within the context of asana
Subtle science
Neuralnervous system is both fragile and mobile
Multi-faceted holistic approach
Neurophysiological effects in restoring homeostasis
Psychoneurological affects (module 2 from science of medical yoga)
copy2001-2015 Ginger Garner
Two Precepts for adaption of neural tissue in response to treatment
1 The nervous system is susceptible to mobilization secondary to the development of tension or increased pressure within the tissue (for example intracranial pressure or intradural pressure) The pressure develops as a consequence of elongation and occurs in all tissues and fluids enclosed by and including the epinurium and the dura mater
1 Movement On closer analysis movement may be considered as gross movement or movement occurring intraneurally between the connective tissues and the neural tissues
gross movement
intraneural movement
Neurophysiological RehabilitationNeural Mobilization
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
38
LLNM
Subjective Neurological Symptoms ndash A Safety Net for practice
New experience for patient
Recognize warning signs and know when to refer a patient for further neurological consult
Always follow the guidelines precautions and contraindications
copy2001-2015 Ginger Garner
Precautions amp Contraindications
Precautions Use caution with the Lower Limb Neural Mobilization if your patient has
PMH or general health problems
Symptoms which increaseDizziness (vertebrobasilar insufficiency or cord tethering) during neck
mm or full spinal flex
Circulatory interruptions Frank cord injury
Loss of bowel or bladder control or paralysis is a medical emergency Call 911
Contraindications Do not use Lower Limb Neural Mobilization if the patient has
Recent onset or worsening of any neurological signs or symptoms
Cauda equina (bowel and bladder function) lesionsSpinal cord injury
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
39
Staff Pose +- Forward Seated Bend
STAFF POSE + FORWARD SEATED BEND (dandasana paschimottanasana)
Slump Test for radicular pain joint mobility meninges mobility peripheral nerves and adjacent tissues
Positive test ndash cervical flexion knee extension and ankle dorsiflexion create LE symptoms and pain or nerve tension is relieved with elimination of 1 or more of lower limb components
Staff (top)
Full staff (middle)
Slump (bottom)copy2001-2015 Ginger Garner
Hand to Big Toe amp Variations
HAND TO BIG TOE (supta padangusthasana)
SLR Test for
Radicular painneural tension
Dura mater tension (ankle dorsiflexion + chin nod)
Sciatic (flexion)
Peroneal (Flexionabd -lateral variation)
HS flexibility amp Contralateral hip flexor flexibility
Spinal integrity
NM awarenessproprioception
Gross stability (contralateral oblique and TvA
control)
Positive test
Reproduction of LE radiatingradicular pain with
passive LE hip flexion and knee extension
Inability to reach 90 degrees for hip flexionknee
extension without SampS
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
40
Neck Flexion
Slump SLR
Isolation of SLR
Var of Slump Test
Adv Slump Test
More Isolation of
SLR
Ankle Plantarflexion
Inversion
Hip Adduction and Hip Medial Rotation
Diagnostics amp Evaluation
copy2001-2015 Ginger Garner
BalanceFactors which impact balance include decreases in Proprioception Visual acuity
Vestibular sense
Sensory deficits
Motor or proprioceptive deficits Joint mobility
Orthostatic hypotension
Pathophysiologies ndash diabetic neuropathy CVA cognitive deficits etc
Age related gait changes include Wider stance Smaller steps
Slower gait Decreased arm counterbalance or reciprocal gait
copy2005-2013 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
41
Practical Application Balance
On teaching balance postures
Introduce one DEGREE OF FREEDOM at a time
Employ Experiential and Academic Learning
Address Static and Dynamic Balance
Address Vestibular Training Tree Pose
copy2005-2013 Ginger Garner
Biomechanics amp Structural
Alignment 4 Principles
Joint function
Properties of connective tissue
Loaddeformation and stressstrain
Lengthtension relationship of muscle
Precept 9
PYT integrates structural alignment the four principles of
evidence-based biomechanics the seven physiological
foundations functional outcomes research complementary
and alternative medicine methods western rehabilitation and psychology with yoga and Ayurveda
copy2005-2013 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
42
Joint Function
Must first define
Closed kinematic chain ndash WB earth bound
Open kinematic chain ndash NWB airether bound
Open packed joint position
Closed packed joint position
copy2005-2013 Ginger Garner
Open Packed Joint Position
Facet (spine) midway between flexion and extension
Sacroiliac counternutation (not locked not able to withstand shear forces in this position only restraint is the long dorsal sacroiliac ligament)
TMJ mouth slightly open
Glenohumeral 55 degrees abduction 30 degrees horizontal adduction
Acromioclavicular physiological position resting
Sternoclavicular physiological position resting
Ulnohumeral (elbow) 70 degrees flexion 10 degrees supination
Radiocarpal (wrist) neutral with slight ulnar deviation
Metacarpophalangeal slight flexion
Hip 30 degrees flexion 30 degrees abduction slight lateral rotation
Knee 25 degrees flexion
Talocrural (ankle) 10 degrees plantar flexion
Metatarsophalangeal neutral
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
43
Closed Packed Joint Position Facet (spine) extension
Sacroiliac nutation (sacrotuberous interosseous and sacrospinous ligaments tighten)
TMJ clenched teeth
Glenohumeral abduction lateral rotation
Acromioclavicular 90 degrees abduction of arm
Sternoclavicular maximum shoulder elevation
Ulnohumeral extension
Radiocarpal extension with radial deviation
Metacarpophalangeal full flexion
Hip full extension medial rotation
Knee full extension lateral tibial rotation
Talocrural maximum dorsiflexion
Metatarsophalangeal full extension
Magee 1992 Lee 2004 2005 copy2005-2013 Ginger Garner
Clinical Implications for Joint Positioning
Beginner vs Advanced
Closed vs Open Packed
Expansion amp Growth
Breath Integration Restraint or expansion of breath
Prevention amp Protection
Biomechanical safety
Postural Education
Biomechanical Safety Net
Dissociation ampor Down-training of Muscle Groups
copy2005-2013 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
44
Muscle Length Dimensions amp Biomechanical Properties
Weppler C H and Magnusson S P PHYS THER 201090438-449copy2010 by American Physical Therapy Association
What is Viscoelastic DeformationTransient
Magnitude
Duration
Dependent on
Duration
Type of stretch applied
10 studies cited plastic deformation change but none used evidence supported by classic model (at right) instead they supported short term elastic or ldquoviscous flowrdquo within connective tissue (or viscoelastic deformation)
Creep - F + T = PD
Equilibrium
Youngrsquos Modulus of Elasticity
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
45
What is sarcomere length
copy2001-2015 Ginger Garner
What are passive and active insufficiency
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
46
What Is So Important about Muscle LengthMuscle Length Biomechanics
If muscle length is not 1-dimensional
4-dimensional
Theory
Length Measure
TensionCross-
sectional area
Time
Then we can determine the biomechanical
properties of
Stiffness Compliance
Energy Hysteresis
StressViscoelastic
Stress Relaxation
Creep
Ozkaya and Norden 1999 Ozkaya and Norden 1999 Taylor et al 1990 Enoka 2002 Magnusson 1998 Magnusson et al 1995 Magnusson et al
1996 Weppler amp Magnusson 2010 Gaoa et al 2013)copy2001-2015 Ginger Garner
A Brief History of Stretch
Static
Constant joint angle stretch
Constant Load
ContractRelax
Repeated cyclic stretches
Visoelastic stretch relaxation (Magnusson amp et al 1998 1995 1996)
Ankle joint predmoninantly tested ndash CPM (McNair et al 2001 Duong et al 2001 Taylor et al 1990)
Passive stretching to evaluate creep (Ryan et al 2008)
PNF withwithout pre-isometric contraction (Magnusson et al 1996)
Diminished hysteresis (see graph) amp Increased flexibility through sustained active stretch (Magnusson et al 1998 Gaoa et al 2013)
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
47
Structural Balance
Yoga Yields Stability Relationship
1 Psychoemotional
ResilienceSports Psychology
Control + Flexibility =Breath + Postures
2 Neuroendocrine Regulation
Control + Flexibility =Breath + Meditation
3 Strength +
Endurance (Power) +
Flexibility Gains = NM Control amp
Neurophysiological Plasticity
Control + Flexibility =
Biomechanical
alignment with Regional Interdependence focus
copy2001-2015 Ginger Garner
Structural BalanceGuidelines to Practice in Integrative Medicine
Optimal Kinematics
Efficient Motion
Enhanced ability to adapt to imposed stresses
Muscle Extensibility amp Sensory Adaptation
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
48
Integrative Medicine Documentation DO
bull Follow SOAP note format
bull Generate List of problems
bull Create list of therapy intentions encased in a specific time frame
bull Short range plan
bull Long range plan
bull Include in final notes
bull For the treatment on day of evaluation (PRN)
bull To the referring practitioner
bull Document clinical rationale for posturalmovement sequence rather than focusing on documenting a list of yoga postures
DO NOT
bull Document Sanskrit postures
bull Document English yoga
postures without including the rationale
bull Identify what you do as only ldquoyogardquo or ldquoyoga therapyrdquo
copy2001-2015 Ginger Garner
Resourcesbull Next Step - On-Site Intensive ndash Module 8
Yoga as Medicine I wwwprofessionalyogatherapyorg
bull Legal Form(s) DownloadIntake Forms for Patients ndash Release of Liability Medical Questionnaire etc at wwwgingergarnercom under Patient Registration
The Tinetti Gait and Balance Test (numerical scoring) can be found at
httpwwwsgimorgworkshop01pdfhandout16TinettiAssessmentTool1pdf
The Timed Up and Go Test (time based scoring) can be found at
httpwwwvagovncpsSafetyTopicsfallstoolkitmediatimed_up_and_go_test-07-15-04pdf
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner
49
Thank you
Empower the Individual
Manage stressPrevent
burnout
Improve patient
compliance and
satisfaction
Overcome adversity Pain
copy2001-2015 Ginger Garner