Depression and anxiety can limit ability to care for one’s self, limit ability to care for a new baby or developing fetus, and can cause mood swings, impaired concentration, and sleep disturbance. Disorders of depression and anxiety are common in the perinatal period (immediately before and after birth) with depression rates around 20% and perinatal anxiety present in about 10% of women. These mood disorders greatly diminish quality of life for mother and baby. Medication may be effective, however, side effects are often unknown, and potentially adverse for the perinatal patient. Many women worry that using medication to treat these disorders may harm the fetus, negatively affect mother child bonding, and poorly influence child development. As health care providers, being aware of alternative treatments for depression and anxiety is essential. Having alternative treatments can allow our patients to combat these common perinatal problems which will improve quality of life, improve bonding between baby and mother and improve the overall perinatal experience. In the general population, positive mental and physical health benefits have been continually demonstrated by yoga participants in current research. Can yoga be an effective, alternative treatment to help perinatal patients improve mental health and well-being?

A recent 2015 systematic literature review published in the Journal of Holistic Nursing reviewed 13 studies to examine existing empirical literature on yoga interventions and yoga’s effects on pregnant women’s health and well-being. The conclusion of the review found that yoga interventions were generally effective at reducing depression and anxiety in perinatal women and the decrease in depression and anxiety was noted regardless of the type of outcome measure used and results were optimized when the study was 7 weeks or longer. Other positive secondary findings noted with the regular yoga participation in the perinatal participants were: improvements in pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being. What is yoga and what form of it may help battle perinatal depression and anxiety?

Yoga by definition is a Hindu philosophy that teaches a person to experience inner peace by controlling the mind and body. Merriam-Webster defines yoga as a system of exercises for attaining bodily or mental control and well-being. All styles of yoga include some combination of physical poses, breathing techniques, and meditation-relaxation techniques. Hatha yoga is the most common form completed in the United States and consists modernly of various postures, breathing, and meditation. In the 13 reviewed studies, all interventions consisted of different forms of yoga and the overall conclusion of the systematic review was the decrease in depression and anxiety was significant no matter the form of yoga completed. Physical and emotional issues such as hormonal changes, sleep deprivation, inability to handle new tasks, self-worth, and body issues, during the perinatal period can contribute to increased anxiety and depression. As health care providers we need to have alternative treatments to help our perinatal patients’ battle depression and anxiety. Yoga is a promising alternative to medication to help decrease depression and anxiety. Additionally it may be helpful for management of pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being.

Interested in learning more about how you can apply therapeutic yoga in your practice? Check out "Yoga as Medicine for Pregnancy this April in Washington, DC!

Sheffield, K. M., & Woods-Giscombé, C. L. (2015). Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women’s Mental Health and Well-Being A Systematic Literature Review. Journal of Holistic Nursing, 0898010115577976.

Reports in the media of research on mindfulness keep reminding us that mindfulness has positive effects on a wide variety of conditions. In the world of pelvic rehabilitation, which is broad when we consider the scope of the patient populations and diagnoses that we treat, we can find benefits from mindfulness to include bladder dysfunction, pain, and even bowel dysfunction. When specifically addressing bowel dysfunction, there are many studies that promote the benefits of mindfulness on bowel health, including the following research findings for the following topics:

Colitis

In 53 patients diagnosed with ulcerative colitis (UC), some were randomized into a control group or a treatment arm that consisted of instruction in mindfulness-based stress reduction (MBSR). While mindfulness-based stress reduction did not, in this study, affect the flare-ups of patients with moderately severe ulcerative colitis, the MBSR “…had a significant positive impact on the quality of life…” when compared to patients in the control group. So even though the use of mindfulness did not appear to affect the disease, the patients utilizing mindfulness perceived a higher quality of life even during a flare of their colitis. (Jedel et al., 2014)

Irritable Bowel Syndrome (IBS)

In another study, 36 people (24 diagnosed with irritable bowel syndrome (IBS) and 12 healthy subjects in control group) were studied. The patients who had IBS were divided into equal groups and were treated with either CBT (cognitive behavioral therapy) or MBT (mindfulness-based treatment.) The authors conclude that mindfulness-based therapy “…is an effective method to decrease symptoms of patients with IBS…” and that it was more effective than CBT at the 2 month follow-up. (Zomorodi et al., 2014)

Irritable Bowel Disease (IBD)

In reference to the importance of addressing mind, body and spirit for patients who have inflammatory bowel disease, this article discusses the benefits of addressing the psychosocial impacts of gastrointestinal disorders, as the disorders are “…best understood by a combination of genetic, physical, physiological, and psychological factors.” (Jedel et al., 2012)

Functional Gastrointestinal (GI) Disorders

Although a recent analysis of studies on gastrointestinal disorders calls for improvement in methodological quality of the research, the article concludes that “…mindfulness-based interventions may be useful in improving FGID [functional gastrointestinal disorders] symptom severity and quality of life with lasting effects…” (Aucoin et al., 2014)

From these few studies we can see that mindfulness is an accepted and potentially helpful adjunct in improving patient symptoms and quality of life in those who have bowel dysfunction. Mindfulness is a tool that every therapist should have in the toolbox for offering to patients who can complete this self-care activity as part of a home program. If you’d like to learn more about how to effectively instruct in mindfulness, you still have time to register for the Caroline McManus continuing education course on Mindfulness Based Pain Treatment, taking place January 16-17 in Silverdale, Washington, on the beautiful peninsula.

Aucoin, M., Lalonde-Parsi, M. J., & Cooley, K. (2014). Mindfulness-Based Therapies in the Treatment of Functional Gastrointestinal Disorders: A Meta-Analysis. Evidence-Based Complementary and Alternative Medicine, 2014.
Jedel, S., Hankin, V., Voigt, R. M., & Keshavarzian, A. (2012). Addressing the mind, body, and spirit in a gastrointestinal practice for inflammatory bowel disease patients. Clinical Gastroenterology and Hepatology, 10(3), 244-246.
Jedel, S., Hoffman, A., Merriman, P., Swanson, B., Voigt, R., Rajan, K. B., ... & Keshavarzian, A. (2014). A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis. Digestion, 89(2), 142-155.
Zomorodi, S., Abdi, S., & Tabatabaee, S. K. R. (2014). Comparison of long-term effects of cognitive-behavioral therapy versus mindfulness-based therapy on reduction of symptoms among patients suffering from irritable bowel syndrome. Gastroenterology and Hepatology from bed to bench, 7(2), 118.

Mindful awareness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment and non-judgmentally, to the unfolding experience, moment by moment.” ^Kabat Mindful awareness can be cultivated through training in sitting meditation, mindful body scan, walking meditation and mindful movement. Over the past 3 decades, a growing body of research has identified multiple health benefits from training in mindful awareness. ^{Keng, Lakhan, La Cour} One pilot study evaluated the feasibility and efficacy of an 8-week mindfulness program for patients with chronic pelvic pain. ^Fox Pre- and post-assessments included daily pain scores, the Short Form-36 Health Status Inventory, Kentucky Inventory of Mindfulness Score and the Inventory of Depressive Symptomatology. Upon program completion, participants reported significant improvement in daily maximum pain scores, physical function, mental health, social function and mindfulness scores. These pilot results are positive and promising.

In my experience, mindfulness gives patients the skillful awareness necessary to self-regulate their reactions to pain and stress. Many of these reactions are maladaptive and amplify distress and pain. With training in mindfulness, patients are able to observe physical, cognitive and emotional reactions to pain and stress and adopt healthy choices that de-escalate suffering. I am excited to share my 30 years of experience and training in mindful awareness and its application to patient care and provider self-care through my 2-day course with Herman & Wallace. Join me at "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain" on January 16-17, 2016 in Silverdale, WA.

1. Kabat Zinn, J.Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2013, 2nd ed. New York: Bantam.
2. Keng, S.L., Smoski M.J., Robins, C.J. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev, 2011;31(6), pp. 1041-56.
3. Lakhan, S.E., Schofield, K.L. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 2013;8(8), e71834.
4. La Cour, P., Petersen, M., 2014. Effects of mindfulness meditation on chronic pain: A randomized controlled trial. Pain Med, Nov 7. doi: 10.1111/pme.12605.
5. Fox, SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med, 2011;56(3-4):158-62.

Carolyn McManus, PT, MS, MA is the author and instructor of "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain". Carolyn is a specialist in managing chronic pain, and has incorporated mindfulness meditation into her practice for more than 2 decades. Today she is sharing her experience by analyzing some of the most foundational research in the field of mindfulness and meditation.

Mindfulness awareness has been described as the sustained attention to present moment awareness while adopting attitudes of acceptance, friendliness and curiosity. (1,2) In patients with persistent pain, mindfulness has shown to reduce pain intensity, anxiety and depression and in improve quality of life. (3,4) Researchers suggest that mindful awareness may work through 4 mechanisms: attention regulation, increased body awareness, enhanced emotional regulation and changes in perspective on self. (5)

1. Attention Regulation: In chronic pan populations, improved attention regulation has been suggested to result in less negative appraisal of pain, greater pain acceptance and reduced pain anticipation. (6)

2. Body Awareness: Improved body awareness has been shown to help patients with chronic pain recognize the difference between muscle tension and relaxation, identify early warning signs that precede a pain flare and reduce maladaptive reactions to pain. (7)

3. Emotional regulation: Training in mindful awareness has been shown to enhance emotional regulation, improve mood and reduce anxiety and depression in patients with chronic pain. (6, 7, 8)

4. Changes in Perspective on Self: In a qualitative study, participants with chronic pain reported becoming less identified with their pain condition or diagnostic label. (7) They felt less “fragmented, experienced a greater integration of mind any body and described the experience of wellness even though they had a persistent pain condition.

I constantly see these changes in my patients who learn to be mindful. Empowered with a skillful way to pay attention, they have greater control over the direction of their mind and thoughts and an increase in body awareness that promotes the ability to relax and the self-regulation of their stress reaction. They avoid escalating distressing emotions and experience a renewed feeling of wholeness and well-being. I am delighted to share my training and experience in mindfulness and years of teaching mindfulness to patients in persistent pain through Herman and Wallace continuing education programs.

1. Kabat Zinn, J., 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. New York: Bantam.
2. Bishop, S.R., Lau, M., Shapiro, S., et al., 2004. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), pp. 230–41.
3. Lakhan, S.E., Schofield, K.L., 2013. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 8(8), e71834.
4. Reiner, K., Tibi, L., Lipsitz, J.D., 2013. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med, 14(2), pp. 230-42.
5. Holzel, B.K., Lazar, S.W., Guard, T., et al., 2011. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Science, 6, pp. 537–59.
6. Brown, C.A., Jones, A.K., 2013. Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness based pain management program. Clin J Pain, 29(3), pp. 233-44.
7. Doran, N.J., 2014. Experiencing wellness within illness: Exploring a mindfulness-based approach to chronic back pain. Qual Health Res, 24(6), pp. 749-60.
8. Song, Y., Lu H., Chen H., et al. Mindfulness intervention in the management of chronic pain and psychological comorbidity: A meta-analysis. Int J Nurs Sci, 1(2), pp.215-23.

Recently in the Pelvic Rehab Report blog we discussed the beneficial role of pelvic rehabilitation for symptoms of dysmenorrhea. Additional research was published this year that supports the use of pranayama for improving quality of life and pain in girls with primary dysmenorrhea. Breathing within yoga studies is a rich field, with well-defined variations in stages and kinds of breathing, techniques and postures, and use of different hand positions and breathing through the nostrils and/or mouth. The Oxford online dictionary defines pranayama as a practice coming from Hindu yoga and related to regulating the breath through specific techniques.

In the study, the practice of both slow pranayama (Nadi Shodhan) and fast pranayama (Kapalbhati) was instructed to the women to be completed in the mornings on an empty stomach for 10 minutes per day. Ninety unmarried young women (ages 18-25) diagnosed with primary dysmenorrhea were randomly and equally assigned to either Group A (slow pranayama) or Group B (fast pranayama). Outcomes included the Moos menstrual distress questionnaire (MMDQ), numerical pain rating pain scale, a quality of life scale "by American chronic pain association" and the assessments were administered at baseline, after the first menstrual cycle, and after the second menstrual cycle. To read more details about the methods and results, the full article can be accessed here.

Prior and recent research has also studied the effects of similar breathing techniques on cognitive functions in healthy adults and also on perceived stress and cardiovascular parameters in young healthcare students. While it may not be new to compare fast and slow pranayama techniques with health conditions, this is the first study to address pranayama's effects on symptoms of dysmenorrhea. The authors conclude that practicing slow pranayama compared to fast pranayama improved quality of life and pain scores related to dysmenorrhea. Furthermore, the authors suggest that because pranayama can decrease absenteeism and stress levels, the practice should be implemented in college students to improve quality of life.

If you are looking to learn more about pranayama and other methods of self-management of conditions including, but certainly not limited to, dysmenorrhea, come to the city-New York City- next month for Meditation for Patients and Providers instructed by faculty member Nari Clemons. It's sure to be hot in the city, so chill out indoors with Nari, and hang out at night with your new favorite colleagues that you'll meet. A benefit of this course is that not only can you learn to care better for your patients, but also for yourselves, and you deserve it.

Patients and practitioners alike can benefit from meditation and mindfulness training for the rehabilitation setting. Nari Clemons joined us today to discuss her upcoming Meditation for Patients and Practitioners course taking place in New York.

We all live in a fast paced world. Our smart phones are letting us know to get back to people with email or texts, we have busy practices with full days, and many of us also have care-giving to do when we get home. Many practitioners see chronic pain patients, sometimes with abuse history or a history of many years of failed medical care. Our patients come to us stressed out and ready to unload, and this happens all day long.

We know our pelvic patients would do better to calm their system. We go home at night so drained sometimes. We would do better to regulate our system. But how? We are all so busy. In Meditation for Patients and Practitioners, we focus on the therapist as well as the patient.

Perhaps you have tried meditation for yourself or your patient. Perhaps you didn’t respond to imagining a waterfall or counting your breath, and you gave up. Perhaps your patient didn’t really take to it, or you can’t figure out how to fit it into your sessions. So many of us know that we are tired of our own low level anxiety, or that our patients would do better if we could get them to re-frame mentally. However, when it comes to implementing those changes, we often come up at a loss.

A randomized control study[1] of nurse leaders who work in understaffed environments were tested with a workplace meditation program. Stress scores were tested at baseline and one week after completing a 4 week program. What do you know? The participants had a decrease in distress scores and an increase in positive symptoms.

“But my day is too busy,” you think? In this course, we work on strategies to center yourself at the beginning of your day, the end of your day, or during your day with 1, 2, or 5 minute strategies. This way, even on your busiest days, you have a way to reel in your stress level and find your calm. For your patients, we offer around 10 different techniques.

When teaching PF1, PF2A and PF2B, we talk about the need to downtrain the nervous system to be effective with pelvic pain, constipation, and history of trauma. Yet, the question always arises about which technique to use with a patient. In the Meditation for Patients and Providers course we give you a working model of how to choose a technique for your patient depending on the time you have, the patient personality, and the situation you are working on resolving.

As one participant said after the last course, “Excellent course. No other course has so beautifully described such practical techniques that are just as important for the therapist’s mental health as they are for the patient’s”. Sound exciting? Join us at the Meditation for Patients and Practitioners course being offered July 19-20 in New York City.

[1]Bazarko, Dawn et al. “The Impact of an Innovative Mindfulness-Based Stress Reduction Program on the Health and Well-Being of Nurses Employed in a Corporate Setting." Journal of Workplace Behavioral Health 28.2 (2013): 107–133. PMC. Web. 2 June 2015.

The following is a message from Nari Clemons, the instructor of Herman & Wallace's new Meditation for Patients and Providers course. You can join Nari at Touro College in New York this July 19-20 at Meditation for Patients and Practitioners - New York, NY!

What doesn’t meditation do? And why aren’t we meditating, already?

I’ve heard it said that if all the benefits of exercise could be placed in a pill, it would be the most powerful prescription. I’m thinking that the same could be said for meditation. We hear little snippets of it as we scroll through the news: meditation for heart disease, meditation for blood pressure, meditation for decreased anxiety. Well, here is yet another study:

Researchers used fMRI technology to examine the brain in 50 people who had been meditating for an average of 20 years and 50 non- meditators. Both groups had the same number of men and women, with ages ranging from 24 to 77. The participants’ brains were scanned, and while age did related to gray matter loss, it was better preserved in those who meditate. **

Americans are living longer, but rates of Alzheimers and Neurodegenerative disease rates are going up. Well, meditation is something you can do to keep on top of your cognitive game. So, why aren’t people meditating? When I ask patients this, I often hear, “I don’t know how” or “I tried it once and I didn’t like it”. I think there is a misconception that mediation should be valued if someone had an experience of bliss or if they are “good at it”.

In fact, meditation is like exercise; it is a benefit that grows as you use it more. It can be hard at first when the mind is not used to being calm or more still. It is not a one-time-use kind of fix. Like exercise, as you do it more, you see more benefits, and you come to like it more. Not everyone who is starting an exercise program will want to train for marathons or be a ballerina or try cross fit. Just as there are different personalities and starting points with exercise, the same can apply to meditation.

In the MPP Herman Wallace course, Meditation for Patients and Practitioners, we break down a lot of the mystery behind learning and teaching meditation. We use techniques of different lengths of time and different aims. We discuss how to pick which technique for which patient or even how to choose a technique for the same patient in a different situation. Going further, we discuss ways to use meditation as a health care provider, so you can share in the benefits of a practice and keep yourself refreshed about your practice. Participants in the course get lots of lab time to develop comfort level deciphering which technique to use and be comfortable teaching and using meditation in their own lives. We also provide a CD with many of the techniques that you will be able to use to refresh course material or to recommend to participants for use in their own homes.

As providers we know that “carrying our patients home” by thinking of them when we leave work or staying sad or anxious about something that happened that day at work is not actually helpful to our patients. Or we may realize we are tired or worn out from the stress of our jobs. Yet, we really don’t know what to do about it. In the MPP course, we discuss ways to keep your job in the space it belongs in your life. This can help practitioners to live a more balanced life, as well as being more present at work.