Casie Danenhauer, DPT - Yoga for Endometriosis (Audience Participation)
Patient Awareness Day 2019: HEALTHY MIND & HAPPY PELVIS
Living Your Best Life With Endo
March 10, 2019 (8am - 5pm)
Einhorn Auditorium, Lenox Hill Hospital, New York City
https://www.endofound.org/patientday/2019
You guys are doing great. It's been a long day. I have the pleasure of being here from California to bring a little, bit of yoga and movement and fresh breath. It's about that time in the afternoon where I know we're all getting a little sleepy and taking standing breaks, so I thought we'd take one together. If you're comfortable, I would invite you to take off your shoes, if you're brave enough. Take a moment. I'm gonna leave mine on. And then, find your way to standing. I know. Requires a little, bit of effort.
And then once your shoes are off and you're standing if that's comfortable, you can also do this sitting in a chair. Just take a peak down at your feet, and notice what's going on down there. Feel your heels as they're connected to the carpet and the ground underneath you. Notice where your toes are, maybe one toe's kind of overlapping. Maybe you're kinda tending to stand all on one side. Just start to bring a little bit of mindful awareness into how you are standing and taking up space in your little person bubble. Okay?
And then if you're comfortable, once you kind of know where you are and where your neighbors are, go ahead and close your eyes, or at least soften your gaze down in front of you. And just take a moment of reflection to just pause and notice. We checked in with our external circumstance, where we are in the room. What's going on inside? What's going on inside physically? Maybe you're still digesting lunch. Maybe you're having some perineal pain from sitting all day. Perhaps you just started your period, and your uterus is talking to you. What's going on emotionally? This is a really intense day for a lot of us. And just allowing space, not judging anything as good or bad, just noticing what is arising physically, emotionally, energetically in this moment.
And then as a group, let's all take a breath in through our nose, and a big sigh on the exhale. Ah. Good. Again. Inhale, this time on your exhale really make some noise. Hah. Okay. Be brave. Loudest one, I can hear. Ah. Nice. Open your eyes if your eyes are still closed, and then give yourself a little shake. Move things around. We'll do another breath exercise. So, you're gonna sweep both arms up overhead, reaching towards the sky. As you bring your arms down in front of you, you're actually gonna make a triangle. So thumb and first fingers touch. And as you exhale, you're gonna bring your hands down across your heart, across your belly, and pause them right above your pubic bone over your pelvis. Actually make contact with your hands and your body, and notice what that feeling feels like. So often we run away from this area of pain when we're dealing with endometriosis or any kind of chronic pelvic pain. Sometimes it's nice to just actually be present, even if there is , but just to be aware of it.
So take another breath in. You're gonna inhale, reach up, exhale slide that triangle, it's called yoni mudra, all the way down the front of your body, connecting to your belly, connecting to your low pelvic area. Again. Inhale. Exhale. Notice what that feels like. You can pause here with that yoni mudra over your low belly. And if it's comfortable, I invite you to close your eyes again. This time, let's do a body scan. So, check back in with your feet. Draw your awareness up through the ankles, the shin bones, calf muscles. Notice what your thighs feel like. Mine feel a little shaky from being a little nervous. Pull up and in through your pelvis and notice what it feels like there. Notice what the front of your pelvis feels like and the back of your pelvis, and then the inside of your pelvis.
Whatever may be present there: scar tissue, organs, the energetic space where organs once sat. Draw awareness up and through your belly, low back, ribcage, your lungs and your heart, across your collarbones, shoulders, down the arms, all the way to each of your hands as it rests on your low belly. Notice the palms of your hands and your fingertips. And then draw your awareness back up through your arms into your throat, jaw, tongue, nose, eyeballs, forehead, crown of head. And then take a big breath where you fill in all those places that just gained your attention. And then exhale. Imagine your feet becoming a little bit more firmly planted into the earth. One more time, breathing in. And breathe out. Awesome. Open your eyes if they're closed. Shake it out one more time. And then you can take a beat.
I'm gonna switch mikes now. Does anyone want to share how they feel with just a simple five to 10-minute meditation and breath practice?
A little better.
Better.
Yeah, better.
Awesome. Okay. So this is me. Thank you for introducing me. My practice, I'm a Doctor of Physical Therapy and a Pelvic Floor Specialist as well. My practice really specializes in what I call conscious care for pelvic health. To me, that means I am looking at not only the physical system, but the emotional, energetic, spiritual systems as they relate to health and wellbeing of a whole person, not just a specific diagnosis or a specific part of their body.
I lead ... I treat one-on-one in the clinic, and then I also, my very favorite thing is education and creating community and group opportunities for education. And I do that through my retreat to your roots. So I teach basically three days of what you're getting in about 15 or 20 minutes. And I do that in workshop format as well.
Like I said, my mission in life and my passion is to spread the word about pelvic health, to empower women through not only education about our own bodies, but through self-care practices and ways that we can connect with ourselves.
So, what is yoga? Who here has practiced yoga? Okay. So, you guys could actually probably do a good job of telling me what yoga is. I might be preaching to the choir. But I hope that I can perhaps give you a few things about what yoga is and how you can use yoga as a potential treatment option or a healing modality with experiencing chronic pain, and specifically endo.
So, literally ... And it's a lot more than what we might think. So, it's New York City, there's yoga studios everywhere. Oftentimes in the West here, we are really just familiar with yoga as the physical practices of yoga, what is known as the Asana. But in fact, yoga's actually a system, a lifestyle almost, or a philosophical model. And literally, the word yoga means to join or to bring union to. And specifically, we're talking about the mind, body, and soul.
So, Pantanjali's Yoga is just one kind of school of yoga, but they talk about the eight limbs. The Yamas and the Niyamas are kind of like the ethical principles or the 10 Commandments of how you're living your life. The practices are the Asana, the physical postures or Pranayama, the breath work practices, similar to something like we just did. Then there are the more meditative or going inward practices, and then kind of what we're all achieving or hoping to achieve maybe one day is the enlightenment or Samadhi, state of ecstasy.
So, just maybe throw out a few styles of yoga that you guys have practiced.
[crosstalk 00:10:09].
Awesome. Okay. So, the answers in the audience are pretty much almost laid out exactly like I separated them. Right? So a lot of people hard of Vinyasa and Power. That tends to be faster-paced. Unfortunately, a lot of yoga teachers in that world are taught to teach fast-flowing yoga, that is focused on zipping up the core, pulling in the pelvic floor, breathing into your, maybe into your belly, but mostly just being really, really strong. Right? Has that been your experience?
Yes.
Okay. Bikram/hot Yoga is intense as well. Iyengar can be fairly intense, but alignment-based. What I would suggest is that we start spending a little bit more time on the right side of this slide. So, Hatha is slow moving physically postures connected with breath. Restorative Yoga, I'm so glad someone said that, it's my favorite. Anyone should be practicing Restorative Yoga, but specifically it's a really nice way to target the nervous system and the fight or flight system that we've been talking about all day, that is present in a chronic pain condition.
Yin Yoga is a slower, kind of less-supported version of Restorative that is often slow-flow as well. Yoga Nidra is a new favorite of mine. I just started practicing this a lot. Nidra translates to sleep, and the goal of Yoga Nidra is to kind of find yourself in this liminal space between asleep and awake. And the idea is that in that state, that is where maximum restoration of the physical, emotional, and energetic bodies can take place. And then Pre and Post-Natal classes might be appropriate if you just had a baby or are pregnant. But might also be really appropriate because generally, I'm speaking very generally, the yoga teachers who are teaching Pre and Post-Natal at least have a little bit more education about certain abdominal conditions, pelvic floor conditions. And even if you don't have a baby or maybe you're not pregnant, oftentimes a lot of the teachers will allow you to come into their class and just either observe or be part of it and just not need to talk about where you are in a Pre or Post-Natal state.
Okay. So why specifically yoga for pelvic health? Well, we kinda just went through this. But, basically, through the practices of yoga, not that physical, not just the physical, but also the physical, meditation, and the breath practices, we're trying to facilitate a mindful awareness whose goal is to basically decrease the fight or flight or freeze state that we often find ourselves in, in chronic pain conditions like endo. And, to increase our safety and a sense of awareness or sense of restful state. And by doing so, we increase our ability to heal, restore our tissues, and have a decreased pain experience.
So, specifically, we have now this subcategory, which is why you're all here of women with endo and why that might be ... why yoga might even be more appropriate. Now we know through the research that women who have endo experience statistically higher rates of chronic pelvic pain and a decreased quality of life. We all know through personal experience or perhaps it's through treating patients, that there's an impact on the physical, emotional, and environmental components of our life. And through all of those aspects, we can either have big-T Traumas, like maybe there's been like a really botched surgery or a really bad experience with a doctor. Or, maybe it's a little-t trauma, that is impacting your system, like someone just discounting your pain or a family member's kinda saying something very slyly off the cuff.
So, in general, this is a multi-factorial disease as we've been talking about all day. And, it requires a multi-modal approach, which is exactly what yoga is. And to be clear, I include it as part of my physical therapy treatment, as one component. I'm not necessarily doing yoga for endo exclusively in my practice, although there are people out there who are.
I like to point out Lorimer Moseley who's a really important pain researcher. He wrote the book Explain Pain, and this website tamethebeast.org has a really great five-minute video on explaining a lot of what we've kind of stepped our toes into today and throughout the weekend. This impact of the brain and the central nervous system on our experience of pain. I will give a very quick example of a research study he did. He took normal college students who signed up for a pain study, so nothing else was wrong with them except they wanted to be in a pain study. And, they hit their knee or their shin with a mallet. And, nothing was ... So there's a control room, which just they're in the room, they get hit with the mallet. Then there was a variable room. So either they were placed into a pleasant-smelling room with like a flower scent or something like that, and then a fart spray room. And it was found that the patients or the participants in the fart smell room, nothing else was different about them, except they rated their experience of pain, the same force of being knocked on the shin, worse than those in the control room or the pleasant-smelling room.
So I put this slide on there, I don't know if you can see it directly, but he talks about the need for there to be a balance of safety inputs and danger inputs. Actually, a minimizing a danger input to have a decreased pain experience. So in that case, the fart spray is actually a danger input to the nervous system as a whole. Does that make sense?
Yeah.
So the key is creating a nervous ... creating safety in the nervous system, and knowing that your nervous system is different than my nervous system, which is different than your Mom's nervous system. And so I would encourage you to start noticing throughout your day what are your safety inputs. What makes you feel a little bit okay. Perhaps it's five minutes of breathing. Perhaps it's hanging out with your puppy. I don't ... It could be different for everyone. Perhaps it is going to pelvic floor PT. For a lot of people, maybe someone's not ready for pelvic floor PT and it's actually a danger input. At that point, I would say, "Okay, this is what I can give to you now. Why don't you go home, practice that for about four weeks, and then come back and maybe we have a different experience."
There was one study done in 2016 that did a yoga, specifically yoga intervention for women with endo. They did sounds like a mix of a class that was community building, physical postures, breath and meditation work two times a week for two hours, for two months. And they did find that they had statistically decreased pain experiences and improved quality of life, compared to the control group, which was just receiving either plain meditation or traditional PT, though they didn't specify if it was pelvic floor PT or not.
So the takeaway here is, what I would like to focus on and what you might be able to focus on in your life would be the physical postures, you're actually getting a good ... The physical benefits obviously of moving your body in certain ways are great. But what is actually, in my opinion, a lot more targeted towards the top-down approach of the nervous system controlling our pain experiences is meditation mindfulness and breath work practices. And of course, you can apply the meditation and mindfulness to any movement you do. So, walking could be your yoga. Hiking could be your yoga. It doesn't have to be these Asanas.
So I'm gonna just offer five main physical postures that I have found and my patients have voted for, so this is patient-created. And I would encourage you guys to consider with any practice or of any exercise really, where you are in your cycle. If you're not tracking it, start tracking it, even if you have irregular cycles. The specific needs of your life in that moment, so maybe you do have a two-year-old who you need to attend to. What's your stress level for that day? And then knowing that your system as a whole today is going to be very different than your system as a whole tomorrow, and that might change your needs and what practices are actually appropriate for you.
So, that's my niece. She's amazing. So we did this already. Breath awareness and meditation. We practiced that a little. There's so many resources out there. I highly recommend Head, Space and Calm, but there's many, many other ones out there as well.
Footwork. So we did a little bit of this. I didn't take you too far into it. But having your shoes off in the ground is actually preferable, if you can actually make that connection to maybe somewhere in the grass or the sand somewhere, is really great. But even in the clinic, I do footwork with my patients because the same nerves, S2, 3, 4 that go to the pelvis and the pelvic floor travel all the way down your legs and go into your feet as well. So we're getting an overflow or kind of an overlapping effect by working on the foot, improving the mobility, the nerve gliding ability throughout the fascia in the bottom of the foot is very connected to what's happening to the system up above.
So tilting your pelvic bowl and pelvic circle. So you can do this in many, many ways. Let's give it a try in sitting or standing, whatever your preference is right now. So if anyone wants to be brave and stand up, that's great. Become aware of your pelvis. So if you're comfortable, it's your body, you can definitely touch it. Find your pubic bone. So, it's usually kind of belly button, you can walk your way down, and as soon as you feel something hard, that's your pubic bone. And then, put your hand on your backside and notice your sacrum, and maybe if you're wearing certain kind of pants you can wiggle your finger into the top of your crack and feel your coccyx, your tailbone. And then slide your hand down and just notice where your hamstring's attach to your pelvis, right at your sitting bones. So you can even lift up one cheek if you're sitting and really just get an idea of where the boney components of your pelvis sit.
Okay. And then place your hands on your hips. And rock your pelvis, just your pelvis, not your body. But rock it forward like you're spilling water out of the bowl that it is. So essentially, it's like I call it cheerleader butt. Got it? Okay. And then, do the opposite of that. So tuck your tailbone underneath you, rock your pubic bone forward so your low back is kind of rounded, and I like to call that cowboy butt. And then, notice what it feels like to rock forward into cheerleader butt, and then rock back. And now, next few rounds we'll keep doing this for a minute, you're gonna inhale as you rock forward. Think of softening your pelvis into the chair if you're sitting. And then exhaling, just rocking back towards your sacrum.
One more time. Breathing in, expand like a water balloon down into the base of your body. And then exhale, just kinda come to neutral. Good. So just ... You can sit down if you're standing. So just simple motions. You can easily take that from sitting to hands and knees, that's cat cow or most of us are pretty familiar with that if we've gone to yoga classes. And then I would encourage you to get experimentational. Experimentational? Experiential?
Yeah.
Yeah. Experimental. And try circles and try figure eights, and actually move this part of your body that might be really frozen and afraid to move. I promise it's safe. I will say, you know your body way better than I do, and if it doesn't feel safe, it's probably not.
This is another one of my favorite positions and a patient voted. It's supported reclined butterfly pose. You can see in the picture, a lot of people are taking different variations. You can use bolsters, blocks, blankets, eye pillows. It's a lot of fun ways to do that. I would hold it ... I think I was teaching this class and we held this pose for about 10 minutes, so I encourage everyone to set themselves up with as many props as they would need to be comfortable in that amount of time.
Supported child's pose, again, another fave. Many versions, but again, use the props, use blankets, pillows, anything that you can get your hands on.
Legs up the wall pose. Supported bridge. Down dog variations. I like to show this sometimes being upside down is really intense for people, so just flipping down dog 90 degrees, taking a generous bend in your knees, even if you're doing traditional downward facing dog, allows for your pelvis to be in that neutral position rather than tucked under, which often happens with tight hamstrings in down dog. And then sphinx pose can be a really nice gentle stretch, especially post-op if you do have scar tissue throughout the tummy.
And then, Satsang in the yoga world is community. And you guys know this because you're here, but I've really found that to be the most important part of connecting, healing, with kind of a sense of you're not alone. And, we've experienced a lot of that today, as people have shared their stories. So that these are a couple of my retreats, and just I love the study that has shown that women's stress response is actually to tend and be friend. Our cortisone and fight or flight response actually goes down when we connect with and speak with and create community with other women.
That's my cat, Stella. She's really relaxed all the time.
And then these are some of my favorite resources. So Amy's book is up there. She's got lots of great information in that book. Dustienne Miller is in Boston. She has a whole yoga DVD for endo. Womb Yoga is a much more energetic and mindful practice that's almost like Qi Gong and Tai Chi. It's a lot of things all mixed into one. And then, my retreats are held a couple times a year, and are basically three days of all sorts of yoga for public health and a lot more.
So, that is all. Questions? Anyone have questions? Yeah.
Actually I have a comment, and I wanted to thank you for the wonderful presentation, and I want to say really appreciate the Endometriosis Foundation taking such a holistic approach. And I do yoga, and I just wanted to make a comment. I wanted to make a little bit of a plug for Iyengar because it does have a restorative component and uses lots of props. And I think it really depends on your teacher. I had a really wonderful teacher who if I told her, "You know, I have cyclic pain." So if I told her I was on my period, then she would make modifications for me and she would say, "Don't do this inverted pose. Try this pose. Here's another blanket. Here's another block."
And I've also found that I can challenge myself. And I guess I'm lucky in a way to do some of the Vinyasa, maybe the stronger work when I'm in the middle of my cycle, when I'm not having pain. And it's been empowering to realize that even though I have maybe not able to get out of bed on day two of my period, I can do some strong work that is safe, depending on the time of the month.
Yeah. Thank you for sharing that. And that's why I really plug cycle awareness. Every patient that walks in, I'm recommending that at their first visit. Thank you.
