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Authors

  1. Zwick, Dalia PT, PHD
  2. Dunn, Mary

Article Content

"My body feels happy in this position."-A multiple sclerosis patient describes the feeling of the half-sitting position.

 

Your patients with disabilities can achieve some of the therapeutic benefits of the standing position-without standing. Amy Moore*, a middle-age woman with cerebral palsy, comes to our clinic and practices standing in the supine position. Alice Potter, a young woman with paraplegia, practices standing in the prone and supine positions before standing upright on a standing tilt table. And Joe Buller, a young man with multiple sclerosis, practices standing in a half-sitting position with his feet parallel and on the wall-a position that makes his body feel happy.

 

These patients enjoy the benefits of the standing position during rehabilitation sessions by using modified or adapted Iyengar yoga postures. The Iyengar yoga tradition focuses on understanding and adjusting key postural alignment elements of biomechanics and motor learning.1

 

Because rehabilitation therapy and Iyengar yoga share ideas and principles, Iyengar yoga can be integrated into rehabilitation to make the sessions interesting and empowering for both therapists and patients. To achieve the best results using Iyengar yoga postures, the therapist should also be a practitioner of Iyengar yoga. The information in this article has been accumulated during ongoing observation, discussion, and collaboration between a physical therapist and an Iyengar yoga teacher.

 

Benefits of standing

People with disabilities can gain physiologic as well as psychological benefits from standing and modified standing activity. "Standing" in a variety of positions with proper support, such as a prone-position blanket under the abdomen, helps preserve joint range of motion and improves muscle flexibility, weight-bearing ability, and bowel and bladder function.

 

Standing, called tadasana, is a key posture, or asana, in Iyengar yoga. By using preparatory asanas-the supine, prone, and sitting positions-a person learns the components of standing. A therapist helps people with neurological impairment get into the standing position and these related poses to achieve the benefits of enhanced elongation: reduced spasticity, spasms, and overall positive influence on abnormal tone.

 

These postures help relieve habitual postural patterns imposed by a disability and allow participants to experience the benefits of yoga postures. People who use wheelchairs and elderly people tend to spend extended periods of time sitting, which leads to soft-tissue changes and joint and muscle contractures. Sitting for long periods also affects bone structure, which leads to osteopenia, osteoporosis, and even changes in bowel and bladder functions. Studies show that assisted standing or passive standing (using a tilt table or standing frame) may help reduce contractures, improve blood flow and bone density, and influence spasticity and internal organ function.2

 

When performed as an Iyengar yoga pose with all its intricacies and attention to detail, standing is a great tool for restoring soft tissues, joints, and muscles and thus easing contractures. But sitting for extended periods shortens soft-tissue structures, muscles, and tendons at the hip, knee, and ankle regions, making it difficult to stand erect. That's why assessment and practice always start in the supine position.

 

Using preparatory poses

Certain physical and medical barriers make standing difficult and at times impossible for people with disabilities.3 Not surprisingly, studies show that those who have higher disability levels and need more assistance standing are less likely to stand.3 Rehabilitation therapists play an important role in teaching people with disabilities about the benefits of standing and in preparing them for this position.

 

People with disabilities can get their bodies ready for standing by practicing several yoga poses with their therapists.

 

In dandanasa, a pose where one sits with the pelvis vertical and legs straight forward (known as "long sitting" in rehabilitation), the relationship of the vertical pelvis to the trunk is similar to that as in standing (below).

  
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The added benefit of this pose is elongation of the hamstrings, which keeps the knee extended as in standing. At first, support might be needed to keep the knee slightly bent. Progression may be done by placing weights on the thighs to increase range of motion into full extension of the knees. In the prone position, the hips are fully extended as in the standing position (below).

  
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These preparatory poses are as important as the final standing posture and can provide many of the benefits of standing. Most poses require an experienced therapist to provide assistance.

 

Some poses require the patient's range of motion to be elongated beyond the midrange into an outer-range. One such pose is setu bandha sarvangasana, a backward bending pose where the extension throughout the spine includes an elongation of the lumbar spine that's carefully guarded by securing a slight posterior tilt position of the pelvis (above).

  
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In this pose, the body is elongated even more than necessary to stand. Patients who are placed into this pose with assistance of the therapist are encouraged to use any active movement they can to help stay in the pose.

 

Elements of standing

The three key elements of postural control in standing are symmetry, steadiness, and dynamics.4 For everyone, whether disabled or not, symmetry in standing starts with the ability to distribute weight evenly between the two feet in an upright stance that continues up through the body.

 

Steadiness and dynamics in standing, which require reflexive muscle activation, are different for people with disabilities. The goal is to achieve steadiness and stability. When the person achieves steadiness, the therapist encourages him or her to take advantage of any dynamic contractile activity of the muscles. The therapist facilitates, encourages, and teaches voluntary movement to assist with any pose, especially the standing position. When people with disabilities are assisted into the standing position, symmetry and alignment are as important as steadiness and dynamics.

 

Therapeutic goal and approach

Amy Moore's cerebral palsy causes more impairment on the right side of her body, and she has flexor muscle spasticity and shortening at the trunk and upper and lower extremities on her right side. Amy spends 10 to 12 hours a day in a wheelchair. Although she has the ability to get up (by holding onto the arm rests) into upright standing, her posture is affected by the long periods of sitting (below, left).

  
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Amy's posture is stooped, and she shifts more weight onto the left leg. She has standing balance impairment and severe back pain. Weakness and tone limit her range of motion at the hips, knees, and ankles.

 

The treatment goal is to reduce pain and improve Amy's posture and balance so she can stand upright in a more symmetrical way. The treatment approach is to integrate Iyengar yoga into her rehabilitation sessions. She's guided, helped, and instructed to practice the standing posture in the supine and sitting positions, which improves her upright standing posture (below).

  
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For patients with disabilities like Amy Moore, rehabilitation therapy using the standing position can provide important physical and psychological benefits. And by using Iyengar yoga postures, these patients can benefit from the biomechanical, neurologic, and motor-control elements of standing without actually standing.

 

References

 

1. Iyengar BKS. Light on Yoga. London, U.K., Thorsons, 2001. [Context Link]

 

2. Bajd T, et al. Problems associated with FES-standing in paraplegia. Technology and Health Care. 7(4):301-308, 1999. [Context Link]

 

3. Eng JJ, et al. Use of prolonged standing for individuals with spinal cord injuries. Physical Therapy. 81(8):1392-1399, 2001. [Context Link]

 

4. Goldie PA, et al. Force platform measures for evaluating postural control: Reliability and validity. Archives of Physical Medicine and Rehabilitation. 70(7):510-517, 1989. [Context Link]

 

*Names have been changed. [Context Link]