Part II: Can yoga mitigate the effects of stress (distress) on our health and wellbeing? An exploration of evidence and practical application

One of the most valuable things that we can learn to do in this lifetime is to care for ourselves.  By optimizing our own physical, energetic, mental and emotional health, we increase our capacity to manage the myriad stressors that impact our day to day experiences.  Investment in our own stability and balance will lead to greater resiliency and ultimately positively impact the relationships we are invested in.

It is often difficult for people to objectively evaluate what stressors they’re experiencing or the degree to which multiple stressors are impacting their health.   In order to do this, an individual can explore the various physiological, mental and emotional symptoms associated with stress (explored in Part I) as well as investigate the presence of specific life stressors over the past year.   One tool that has been in use since 1967 is the Holmes and Rahe Stress Scale.  This scale adds up the number of “life change units” that apply to conditions over the last year of a person’s life.  The results provide a rudimentary evaluation of how the last year has affected one’s health.

Holmes & Rahe Stress Scale

Score of 300+: At risk of illness.

Score of 150-299+: Risk of illness is moderate (reduced by 30% from the above risk).

Score 150-: Only have a slight risk of illness.

Once this evaluation is complete, we need to look at what steps one might take to proactively manage their life situation, and further, examine where yoga fits in on the spectrum of management techniques.

Varvogli and Darviri (2011) in their comprehensive literature review identified 10 evidence-based techniques that have been shown to reduce stress and promote health. These techniques include the following;

1. Progressive Muscle Relaxation: the progressive tensing and relaxation of muscle groups in a specific or sequential pattern.  The practice is repeated 2-3 times daily for 15-20 minutes per session.  This technique is effective for insomnia, decreasing generalized anxiety, decreasing heart rate and blood pressure and improving quality of life in chronic illness such as heart disease and multiple sclerosis.[i]
2. Autogenic Training (AT): a self-relaxation procedure consisting of six standard exercises that use visual and verbal cues to make the body feel warm, heavy and relaxed. The exercises are practiced for a few minutes several times per day.  There is evidence that AT is effective in treating headaches/migraines, heart disease, modifying stress for asthma, pain, anxiety disorders, moderate depression and functional sleep disorders.[ii]
3. Relaxation Response (RR): facilitation of the relaxation response involves two components; the first is the repetition of a word, sound, prayer, thought, phrase or muscular movement so that concentration is achieved.  The second component is the return of attention to that repetition when concentration is broken.   This technique is practiced 10-20 minutes each day resulting in  an overall decrease in arousal return to normal digestive and hormonal functioning.  There is significant evidence showing that the RR positively impacts cardiovascular disease as well as long-term physiological effects associated with gene expression.[iii]
4. Biofeedback: a technique whereby a trained professional uses instruments to relay physiologic information to the individual.  Over 3-6 months of sessions, the individual is able to observe changes in heart rate, blood pressure and respiration and to eventually effect changes in these same measurements.  This technique has been shown to be effective for headaches, cardiovascular disease and type II diabetes. [iv]
5. Guided Imagery (GI): is a technique that uses images to promote health and relaxation in a safe environment, typically recruiting visual, auditory, olfactory, tactile and kinesthetic senses.  The practices a minimum of 10 minutes per day. GI has proven to be effective in stress reduction, treatment of depression and anxiety, for pain management and management of anxiety over medical procedures.[v]
6. Diaphragmatic Breathing: is a technique that focuses on slow deep diaphragm focused breathing.  It has long been one of the essential tools of yoga and best results are achieved if this practice occurs several times daily.  This practice resets the autonomic nervous system and has been used to reduce anxiety, in management of acutely stressful situations as well as treatment in hypertension.[vi]
7. Transcendental Meditation™: involves repetition of a mantra for 20 minutes twice a day.  There is evidence that TM improves brain function, attention, resilience, self-esteem and mood, as well as reduces anxiety, pain, depression and stress.[vii]
8. Cognitive Behavioural Therapy (CBT): is a structured, time-limited, specific technique that involves assessing and cognitively restructuring dysfunctional behaviours and emotions. The technique is utilized between a trained clinician and patient.  CBT is used effectively to treat pain, headaches, cardiovascular disorders, diabetes, obesity, depression and stress related to infertility, anxiety and stress management.[viii]
9. Mindfulness-Based Stress Reduction (MBSR): is a structured 8-week program utilizing mindfulness meditation to ameliorate mental and physical stress associated with physical, psychosomatic and psychiatric disorders. MBSR has been used to successfully modify mood, pain, enhance immune function, reduce stress, anxiety and depression.[ix]
10. Emotional Freedom Technique (EFT): involves tapping on nine acupoints while speaking aloud a meaningful and specific phrase.  This is an exposure technique used in conjunction with a trained professional. It is particularly useful in post-traumatic stress disorder and trauma following illness or medical intervention.[x]

It is worthy to note that there is evidence that physical exercise modifies anxiety, improves self-esteem and most importantly protects against the long-term consequences of stress.[xi]  Unfortunately, most of the research examining the relationship between exercise and stress has looked at aerobic activities such as running, aerobics etc.  It would be interesting to see if the same relationship was established when examining more challenging styles of yoga.

If we examine a comprehensive yoga practice, the common elements include asana (physical practice), pranayama (breathing techniques), meditation, chanting, relaxation, and possibly yoga nidra.  It is clear from the above evidence that practicing meditation, chanting and relaxation has measureable effects our stress response and as such is imperative to the practice. We will explore asana, pranayama and yoga nidra in more detail here.

Asana:

The majority of North American practitioners are introduced to yoga through the physical practice, which ultimately or ideally stretches contracts and relaxes all the muscle groups of the body.  This is coupled with cultivation of present moment awareness and diaphragmatic breathing.  Interestingly, one might conclude that the simple process of asana itself includes facets of progressive muscle relaxation, the relaxation response, diaphragmatic breathing, and the mindfulness cultivated in the mindfulness based stress reduction technique. One might also specifically utilize specific styles of yoga for particular effects.  For example yin or restorative yoga may elicit a more profound relaxation response or cultivate a greater foundation for mindfulness.  A breath focused style of vinyasa yoga may more effectively cultivate diaphragmatic breathing and strength-based or power yoga might most effectively reap the benefits of aerobic exercise.

Pranayama:

          Pranayama involves altering 3 aspects of the breath: Inhalation (Puraka), Exhalation (Rechaka), the Pause (Kumbhaka).   Pilot studies at the START clinic in Toronto (Stress, Trauma, and Anxiety Rehabilitation Toronto) have determined that 5-6 breaths per minute optimally balances the sympathovagal stress response system for most adults.[xii]  Interestingly this is approximately a 5-count or 5-second inhale/exhale which is what is used in most breath-based vinyasa classes.

The Bihar school of Yoga has also listed the following pranayama practices as “tranquilizing” or “balancing” in nature:

Candra Bedha Pranayama or Candra Bedhana (Moon Piercing Breath)[xiii]

• Tranquilizing Pranayama
• “Candra” is the moon – this technique focuses on ida nadi
  • Technique:
    • Block Right Nostril, Inhale Left Nostril
    • Block Left Nostril, Exhale Right Nostril
    • Practice 10 Rounds
  • Practice Notes:
    • After 10 rounds, you may introduce bandhas, breath retention, and mudra (shambavi mudra)
    • Gradually increase the length of inhalation and exhalation
    • Suggested ratios are 1:1:1, moving to 1:2:2, moving to 1:4:2
    • It takes a longer duration of time to breathe through one nostril only, so bear this in mind when establishing duration of inhale/exhale
    • Practice only 10 additional rounds with bandhas, retention and mudra
  • Benefits:
    • Creates mental introversion, calmness and enhanced psychic abilities
    • Cooling for the system and enhances all attributes associated with ida nadi
  • Contra-indications:
    • Do not practice if you are introverted by nature or suffer from serious mental disturbance
    • Do not practice if digestion is sluggish or if there is excess mucous in system

Nadi Sodhana (Nadi = channel, Sodhana = purification)[xiv]

• Balancing Pranayama for psychic network purification.
• Utilizes right and left nostrils to influence ida and pingala nadis.
• Profound practice as it can bring equilibrium to physical, energetic and mental bodies, as well as enabling one to direct prana for spiritual awakening.
• Nasikagra Mudra is used: 2 fingers on 3rd eye, thumb used to block and open right nostril, ring finger used to block and open left nostril.
  • Technique: There are 18 stages of nadi sodhana for beginner, intermediate and advanced students – the beginner technique will be described here.
  • Beginner Techniques:

Step One:

• Sit in sukhasana, ardha padmasana or vajrasana
• Perform nasikagra mudra
• Block Right Nostril, Inhale and Exhale five times through Left Nostril
• Block Left Nostril, Inhale and Exhale five times through Right Nostril
• Keep both Nostrils Open, Inhale and Exhale five times through both Nostrils together
• There is no limit to the number of repetitions that may be performed for Step One.

Step Two:

• Repeat the same process as step one, however regulate the count of the Inhale and Exhale so that they are the same.
• I.E.: 4:4, or 5:5, or 6:6 etc.

Step Three:

• Block Right Nostril, Inhale evenly through Left Nostril
• Block Left Nostril, Exhale evenly through Right Nostril
• Keep Right Nostril Open, Inhale evenly
• Block Right Nostril, Exhale evenly through Left Nostril
• This is ONE round
• Practice 15 rounds

Step Four:

• Repeat the same process as step three, however regulate the count of the Inhale and Exhale so that they are the same.
• Start with a count that is comfortable and stay with that count for a period of time before attempting to increase it.
• May time the breath to a Mantra (i.e.: OM)

Step Five:

• After 15 days of continuous practice with step four, you may go on to step five.
• Practice as in step four, however double the exhale so that the ratio is 1:2 (or 1:0:2:0).
• Benefits:
  • Can be used as a therapeutic tool for virtually all conditions.
  • Pranic channels are purified and decongested
  • Controls fluctuations in mind~body balance
  • Restores equilibrium in mental, emotional, physical, energetic bodies
  • Increases resiliency with all life situations
  • It is a complete practice in itself that can be used to direct prana into sushumna for spiritual awakening
• Contra-Indications:
  • Individuals with high BP, heart disease or peptic ulcer should not practice beyond step five of the beginner techniques.

 Yoga Nidra (Yogic Sleep)

Yoga nidra is a systematic technique for cultivating multidimensional (physical, mental, emotional) relaxation consciously.   Ideally the technique is practiced daily, however studies have shown significant self-reported results in reducing anxiety for sufferers of post-traumatic stress disorder in as little as two sessions per week.[xv]   According to the Bihar School of yoga, yoga nidra can be used to treat a variety of conditions including insomnia, fertility issues,  chronic cardiovascular and gastrointestinal diseases, psychological disorders and psychosomatic illness.[xvi]  Currently, there is significant investigation and exploration around these claims.

Anecdotally, when one practices yoga nidra, it is evident that there are elements of relaxation, visualization, mindfulness and even autogenic training in the practice.  The experience is actually quite profound.  For further exploration, try listening to these recordings every day for 4-6 weeks and see how you feel. http://traceysoghrati.com/download_audio

Conclusions:

          Based on the available evidence, a comprehensive yoga practice should be efficacious in modifying levels of stress.  It seems to be essential that the components of the practice are repeated frequently and that the relaxation response is mediated at the level of the body, breath and mind.  The key is to try it out for ourselves.

References

[i] Varvogli, L. & C. Darviri. (2011) Stress Management Techniques: evidence-based procedures that reduce stress

Part I: What is stress and how does it affect us?

Part II: Can yoga mitigate the effects of stress (distress) on our health and wellbeing? An exploration of evidence and practical application (August 2012)

Perhaps one of the most remarkable things about living on the planet at this time is our unparalleled access to the rest of the world. We are literally tapped in to a global web of technology, communication, information and ideas. The beauty of this is that our knowledge is growing exponentially every day, and with that our hunger to see, feel and understand more. The flip side of this is that knowledge doesn’t equal wisdom – and while we feed our increasing hunger for stimulation, our body pays the price.

The health costs of being overwhelmed or “stressed” are increasingly examined, especially as growing numbers of the population are self-identifying as being stressed out, anxious or depressed. According to the Canadian Mental Health Association, 20% of the population will personally experience some form of mental illness in their lifetime. Further to this, Health Canada has noted that “Stress” is a risk factor in heart disease, some bowel diseases, herpes, and mental illness, as well as a complicating factor in diabetes.

Yoga teachers and practitioners often claim that practicing yoga (asana, meditation, pranayama and svadhyaya) modifies both stress levels and the deleterious effects of stress on the body. Fortunately, Yoga Therapists are more consistently conducting evidence-based research, through which we can examine these claims. This research will allow us to intelligently apply yoga practices to the individual and ideally achieve measurable results.

What is Stress?

“Stress is a biological term which refers to the consequences of the failure of a human or animal to respond appropriately to emotional or physical threats to the organism, whether actual or imagined. It includes a state of alarm and adrenaline production, short-term resistance as a coping mechanism, and exhaustion. Common stress symptoms include irritability, muscular tension, inability to concentrate and a variety of physical reactions, such as headaches and elevated heart rate.”[i] (Hans Selye)

The fascinating aspect of this definition is that it identifies that our stressors can be “real or imagined”. This indicates that there will be a physiological response even if we are only imagining a stressful scenario.

Hans Selye (founder of the Canadian Institute of Stress) further outlined Stress via his model of General Adaptation Syndrome, which looks at how we manage or tolerate stressors over time;

Stage 1: Alarm: Activation of the Sympathetic Nervous System and secretion of Cortisol.

Stage 2: Resistance: The body attempts to adapt to a persistent stressor and resources gradually deplete.

Stage 3: Exhaustion: The resources of the body are depleted and normal function is impaired. Long term damage may result from extended stimulation of the organs and impairment of the immune system. This may present as: ulcers, depression, diabetes, digestive disorders, cardiovascular disease and mental illness.

Interestingly, Selye found that stress can be divided into two general categories:

Eustress: stress that enhances function (i.e.: Exercise).

Distress: depresses function and leads to the presentation of physical and mental disorders.

Stress is modified through perspective (our perception of events), relaxation of the sympathetic nervous system and facilitation of the parasympathetic nervous system.

Symptoms of Stress:

Dr. Earle, the current director of the Canadian Institute for Stress advises that anyone experiencing two or more of these symptoms on a regular basis should take steps to decrease stressors in their lives.

Stress and the Brain:

According to McEwen (2008), the brain determines what is stressful as well as our physical and behavioural response to actual/potential stressors.[ii]

The brain initiates three general pathways in order to defend itself against stress:

1. Hormones: uppers, modulators and downers (i.e.: epinephrine, nor-epinephrine and cortisol)
2. Inflammatory Cytokines: They may be Pro- or Anti-inflammatory
3. Sympathetic Nervous System: “Fight, Flight, Freeze, Play Dead response” Versus Parasympathetic Nervous System: “Rest and Digest response”.

Sympathetic Nervous System

• The sympathetic nervous system (SNS) supports the whole body in its flight or fight function by gearing up the internal organs and musculature for emergencies.[iii]
• This stimulation of the nervous system occurs when our senses detect either danger or the need to be alert.
• Epinephrine (adrenalin) is released from the adrenal medulla in response to the SNS.  It activates the body globally when stimulated.[iv]
• Cortisol is also released, which is a corticosteroid hormone produced by the adrenal cortex. It increases blood pressure and blood sugar, and reduces immune responses.
• The heart rate increases.
• Respiration rate increases.
• Glucose is released from the liver for energy.
• Pupils dilate.
• Arterioles constrict in the digestive system and skin so that blood is shunted away from these areas (increases blood pressure). The hands and feet become cold due to the vasoconstriction.
• Sweat glands flood the surface of the body making the skin clammy.
• Arterioles in the heart dilate.
• Sphincters in the GI tract constrict.
• The senses become sharper.
• These physical changes increase your strength and stamina, speed your reaction time, and enhance your focus – preparing you to either fight or flee from the danger at hand.

Parasympathetic Nervous System

• The Parasympathetic Nervous System (PNS) is the complementary partner to the SNS in the autonomic nervous system.  It is the “Rest & Digest” response.
• In contrast to the SNS which is global, the PNS is organ specific.[v]
• In relation to the SNS the PNS only balances out functions of respiration and heart rate.  Otherwise it presides over specific organ functions.
• Stimulates digestion by facilitating peristalsis, and production of saliva and digestive enzymes.
• Stimulates sexual arousal.
• Slows heart and respiratory rate.
• Facilitates elimination.
• Parasympathetic activity has anti-inflammatory effects.

Part II: Can yoga mitigate the effects of stress (distress) on our health and wellbeing? An exploration of evidence and practical application (August 2012)