Friday Q&A: Carotid Artery Stents, Baroreceptors, and Inverted Poses

The Carotid Artery

Q: Perhaps you will have an answer for this, to me, pressing question. Stent placement in one or both carotid arteries has become more and more common. How does this impact the baroreceptors ability to reduce blood pressure during inversions? If you have a stent, what are the limitations on practicing inversions? Should they be only mild, or are moderate or full okay for limited duration? If so, about how long/ Is it ever safe to practice full inversions after a stroke? 

A: Before discussing whether or not to practice inverted poses with this condition, let’s start with discussing the “what” and the “why” of stent placement in the carotid artery. Just as you can develop narrowing of and blockages in the arteries around the heart (coronary artery disease, which can cause heart pains and lead to heart attacks), you can also develop narrowing of and blockages in the main arteries to the brain, the carotid arteries, located in the neck. In many cases, experiencing a stroke or mini stroke is the first indication you may have such a blockage. Carotid artery disease can also lead to gradual cognitive changes and contribute to the development of dementia, even in the absence of stroke. 

For a long time now, the main way of opening these blocked arteries back up when they become significantly closed was to do a surgical procedure called carotid endarterectomy, where the vessel is opened up and the blockage is removed. This is a major neck surgery done under general or regional anesthesia. As our reader points out, there is now a newer and less invasive technique that does not requiring anesthesia called carotid artery stent placement. Similar to the method used for stent placement in the vessels of the heart, with this technique a catheter is inserted into a major blood vessel in the groin area and threaded up into the carotid artery where the narrowing or blockage is, and a stent is placed there, which expands outwards to reopen the blocked passage. 

Typically, you would undergo one or the other of these procedures if you had signs and symptoms of narrowing of the arteries or had already suffered a stroke, leaving you at risk of having a first or repeat stroke if left untreated. Often, patients in this situation have multiple other health issues going on, such as high blood pressure, diabetes, high cholesterol, history of smoking, and other heart issues, and with that are often on multiple medications to try to address said problems. So, this can be a more complex issue than simply having one blocked blood vessel, making it difficult to generalize how this may impact your yoga practice. 

Now, let’s assume you have had a stent placed in one or both carotid arteries. What is the effect on the functioning of the baroreceptors in that neck region and how might that impact blood pressure after the patient has healed from the procedure? (I am not going to go into detail on the effects during or right after such a procedure, since I am assuming this reader has successfully undergone stent placement and is now returning to regular activities.) It turns out that for some people their blood pressure ends up lower after the procedure! This may be a result of the outward pressure of the stent stimulating the baroreceptors to respond as if the blood pressure is higher, which in turn causes the brain to lower the blood pressure in response. 

This effect has been seen to persist for up to a year in those who respond this way. In many cases, these folks can lower their dosage of high blood pressure medications. It also is known that even a slight decrease in blood pressure lowers the chances of stroke down the road, so people who have decreased blood pressure after stent placement have a reduced long-term risk of stroke. In addition to the lowering of blood pressure seen in some patients, baroreceptor sensitivity usually returns to normal six months after a stent placement for those with or without the blood pressure changes noted above. So, all the baroreceptors, both on the aorta and in the carotids, would detect changes in blood pressure in a healthy way, leading to normal responses by the brain. 

That said, I was not able to find any studies looking at the ability of the baroreceptors in someone who has had a stent placed to lower blood pressure in yoga inversions. So, as always, and especially in complicated medical conditions like this, it is essential that you discuss with your specialist doctor to get their recommendations regarding cautions in your yoga practice. 

I did ask cardiologist friend of mine what his recommendations might be for reintroducing inversions into a yoga practice in this particular situation (realizing that his recommendations are not applicable to individual cases without seeing the patient for an evaluation). Fortunately, he has some basic understanding of yoga poses and practices. His recommendation was clear: If the person had already had a stroke, he said to avoid inversions, as the risks—which include worsening the stroke or precipitating a new one, as well as possible dizziness and fainting—outweigh the benefits. In fact, he is quite conservative when it comes to patient care for anyone who has already developed carotid artery disease, as it means there could already be changes to blood vessels in other areas, especially possible changes to the flow of blood in small vessels of the brain, and this puts folks at risk of bad outcomes. He’d recommend skipping them altogether, as he feels the risks outweigh any benefits of doing inversions, and focus on the non-inverted poses and other seven limbs of yoga instead. 

Of course, it is possible your physician will have a different take on the risk/benefits of reintroducing inversions in this situation. So, for those who get the okay from their health care team to reintroduce inversions, I recommend you begin with the more gradual and/or supported inverted poses. 

For those that can be done dynamically, such as Downward-Facing Dog pose and Bridge pose, start there and see how your body handles them before holding them statically. Make sure there is no dizziness, lightheadedness, rapid heartbeats, sudden headaches, or anything else that feels like a worrisome response to inverting. After practicing the dynamic version for a period of time and feeling acclimated, you can introduce short holds of 15-30 seconds, coming out of the pose for a few breaths, and possibly repeating it a second time, assessing your body’s response as with the dynamic versions. Over time, you can gradually add more time in the pose as tolerated. You can also use dynamic poses to prepare for a pose that can only be done statically. 

You can also gradually work your way up to a classic supported inverted poses by first practicing some dynamic poses and then practicing the most gentle variation of the inverted pose and work your way up to the full pose. For example, let’s take one of my favorite supported inversions, that is generally safe for most practitioners in most situations, Legs Up the Wall. 

For example, to prepare for classic Legs Up the Wall pose, you could do the following sequence: 

1. Use Dynamic Upside-Down Downward-Facing Dog pose to prepare your body for the general shape of the pose without having to hold it (see youtube.com ). 

2. From there, you would progress to the most gentle version of Legs Up the Wall pose, where your pelvis is on the mat and your calves are resting on the seat of a chair. (We sometimes call this Relaxation pose with a chair or Easy Inverted pose.) 

3. You can then progress to the version where your pelvis is on a bolster and your legs are on the chair. 

4. Eventually, you could progress to the classic version of Legs Up the Wall pose, with your pelvis elevated on a bolster and your legs up the wall (for instructions, see Featured Pose: Legs Up the Wall Pose ). 

You could take a similar approach to classic Downward-Facing Dog pose: 

1. Begin with Dynamic Downward-Facing Dog pose (see youtube.com ). 

2. Move to short holds of the chair version of Downward-Facing Dog pose (see Featured Pose: Downward-Facing Dog Pose). 

3. Finally, practice the full pose (see Featured Pose: Downward-Facing Dog Pose). 

Finally, if you are told that inversions are too risky for you at this time, remember that there are other yoga tools you can practice to access one of the main benefits of inversions, the triggering of the relaxation response. See Nina’s post The Relaxation Response and Yoga to learn more. 

By the way, this is the second Friday Q&A regarding the practice of inverted poses with a specific health condition. see Friday Q&A: Pituitary Tumor and Yoga for the first one.

—Baxter

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Achieving a Flow State with an Asana Practice

by Nina

The Willows on the River by Claude Monet

In yesterday’s post The Benefits of Distraction: Tetris vs. Yoga, I wrote that yoga was a better alternative than Tetris (and other similar forms of distraction) for getting into a flow state to help with anxiety, worry, and other negative emotions. But how exactly do you use yoga for this purpose? With meditation and pranayama, obviously you just practice as you normally would. But how would you achieve this state with your asana practice? Can you just do any asana practice at all? Or, are there some basic requirements that you will need to meet?

Yeah, I’m sure you’ve figured out by now that you can’t just quickly run through a random set of poses while watching TV. But the basic requirements—as I figure it—are not too demanding:

1. Practice at the right level of challenge for you.

2. Practice mindfully, with a mental focus.

Let’s take a closer look at both of these requirements.

Practicing at the Right Level for You

There needs to be some level of challenge in your practice if you want to achieve flow. Ram put it this way:

“When one is engaged in an activity where the challenge matches the individual’s skill, that is, when a person's skills are fully involved in overcoming a challenging task.”

So, while there is a time and place for doing restorative yoga or just enjoying your favorite basic poses, a super comfy, easy practice won’t engage your mind completely. (The only caveat to this being that if you did those practices with your mind well focused on your breath, that would might also work. But, remember, the goal here is "distraction" and "flow" not just physical relaxation.)

On the other hand, if your practice is too challenging (something we don’t recommend doing anyway) that will lead more to frustration than flow.

In fact, in the study A better distraction: Exploring the benefits of flow during uncertain waiting periods. discussed briefly yesterday, they tested the subjects with three different levels of Tetris: very easy, very challenging, and just challenging enough. 

So, we’re basically in Goldilocks territory, with you yourself needing to figure out what kind of practice is “just right” for you. And you might have to do some testing, as Goldilocks did. But, if you haven’t read our post How to Stay Safe While Practicing Yoga, you should check that out. Because you definitely want to follow those guidelines to help you know when you should back off on the challenging poses or practices.

Finding a Mental Focus

While there are many benefits you can get from practicing yoga poses with a wandering mind or one that is distracted by music, radio, or TV, to get into a flow state you need to do your poses mindfully, which requires both concentration and practicing without self judgment. There are many different ways to practice asanas mindfully, so, again, like Goldilocks, you may need to experiment to see what engages your mind the best. And, in fact, you may need to change up what you do, as doing it the same way will probably create a routine quality that begins to bore you a bit.

For general information on practicing yoga mindfully, see Practicing Yoga Mindfully. In this post, you can learn about how Jon Kabat-Zinn recommends practicing yoga poses mindfully.

For information on how to practice breath awareness, which is always a good way to have a mental focus in just about any pose, see A Balm for the Soul: Practicing Simple Breath Awareness. If you're stuck in a rut with the way you currently practice breath awareness or if doing so makes you anxious, check out this post for ideas of other ways to do it.

For information on various ways to use your seven senses as a point of focus, see Coming to Your Senses in Yoga Poses. If you haven't read this post, you may be surprised to learn how many senses we actually have and what a variety of ways there are to use them as we practice.

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For information about Nina's upcoming book signings and other activities, see Nina's Workshops, Book Signings, and Books.

The Benefits of Distraction: Tetris vs. Yoga

by Nina

These seem like particularly anxious times (I had trouble concentrating on my work yesterday, did you?). But even when they are not, there is always plenty to worry about. Fortunately, according to some scientists, playing Tetris can help. They proved this in a kind of silly sounding study A better distraction: Exploring the benefits of flow during uncertain waiting periods., published in the Journal “Emotion,” where they made people anxious by telling them they were going to be rated on their attractiveness and then had them play Tetris while they were waiting to be assessed, if indeed they were ever assessed because the playing Tetris part was the actual assessment. 

So why am I telling you about this? I don’t even like Tetris, myself, though I realize it has many fans. But what interested me about this story, which I heard on NPR, Can't Stop Worrying? Try Tetris To Ease Your Mind, was that the scientists picked Tetris because playing it at the right level puts you into a flow state, which Kate Sweeny, UCR researcher, defined as, “"The state of flow is one where you're completely absorbed or engaged in some kind of activity. You lose your self-awareness, and time is just flying by." And that’s what they were actually trying to study—whether being in a flow state would reduce anxiety. Their conclusion was that, yes, it does. 

“The Tetris study is key because it experimentally manipulates flow and shows effects of that manipulation, which provides convincing evidence that flow actually causes well-being during waiting periods, not that it just happens to coincide with well-being.” —Kate Sweeny

And I remembered from Ram's post Positive Psychology vs. Yoga Philosophy what a flow state is and how he concluded that yoga was the perfect way to get into that state: 

“The breath work, concentration, precise alignment, the controlling power of how hard you’re pushing yourself—all of this puts an individual in a flow state. It was as though Patanjali designed the entire yoga philosophy to provide a flow experience.” 

Of course, I have been saying for ever so long that yoga can help with negative emotions, including stress, anxiety, depression, sadness, etc., partly because the mindful way you practice provides a break or distraction from the difficult emotions you are experiencing in your everyday life. And distraction is exactly how the scientists identified the benefits of playing Tetris. Here’s a quote from the abstract of the study itself: 

“A worrisome period of uncertainty frequently precedes important life events, and many of the coping strategies people employ during such waiting periods are ineffective. Distraction can be efficacious, but individuals awaiting uncertain news often fail to lose themselves in a sufficiently diverting activity. Across three studies—two observational and one experimental—we test whether flow-inducing activities provide a better distraction and improve the waiting experience.” 

The thing is yoga offers so much more than just distraction, including improving physical skills (strength, flexibility, balance, and agility), stress management, brain health, cardiovascular and heart health, and pain management and other medical benefits, not to mention increased equanimity and contentment. So, yoga seems like a much more effective choice when you need distraction from anxiety and worry, especially because of its long-term benefits. However I do admit that getting into a flow state with Tetris is a bit more portable than yoga because while you can practice everywhere and anywhere, it’s not always possible to get into a flow state while you are, for example waiting in line to vote or at the Department of Motor Vehicles, or even on a plane while you are crammed in between two strangers. In those cases, Tetris might be a good option, so if you love Tetris, go for it! 

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Yoga and Human Rights

by Jivana

Mural of Human Rights: The Seeds That Give the Fruit (Detail)
by Vela Zanetti

“Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world, Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people.” — Universal Declaration of Human Rights, United Nations, 1948

I imagine that for most people talking about yoga and human rights in the same sentence may seem strange. But this connection became clear in my mind when I had the privilege of attending a special event at the United Nations Human Rights Commission in Geneva in 2015. The event was the celebration of the International Day of Persons with Disabilities, December 3, a holiday established by the UN. That year, I was invited to teach Accessible Yoga as part of a variety of offerings focusing on the positive steps that people with disabilities can take to achieve full equality and human rights. 

Most of the other presenters were leaders of disability rights groups from around the world. They spoke about how people with disabilities make up the largest minority group in the world: well over 1 billion people! And they discussed the basic human rights that they are seeking for people with disabilities. In 2006, the UN’s Human Rights Commission set the gold standard for these human rights in their Convention of the Rights of Persons with Disabilities. They declared: 

“The purpose of the present Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.” Article 1, United Nations Convention on the Rights of Persons with Disabilities

I was struck by the correlation between basic human rights, and the fundamental teachings of yoga philosophy. According to the yoga tradition, each person has a spiritual essence, which is called the atman or purusha. The work of yoga, the poses, breathing practices, ethical living, and meditation, are all about opening the pathways to the experience of that essence. I’ve always loved the fact that yoga begins with this positive assumption. The idea is that every single one of us has an atman, and that there is no differentiation made between the atman of any two people, regardless of their ability or background. Yoga begins with equality, as we are all equal in spirit. And because we are all equal in spirit, yoga is equally powerful in helping anyone, of any background or ability, to find the inner peace that we all crave.

Of course, embracing diversity is an essential part of human rights, and the disability community is extremely diverse. There is currently a shift in the disability community towards disability pride, towards embracing difference. As a gay man, pride has a special meaning to me. I grew up thinking that being gay was a deficit, and learning to be proud of my differences has been a great source of my healing. Now, I am not only proud of being gay, but I see how being different makes me stronger.

Swami Sivananda, a famous yoga master, used to say that spiritual life was about seeing the “unity in diversity.” This means being able to see that we are all connected, and to simultaneously embrace our differences. Yoga and human rights both stem from this dual vision—the ability to hold both equality and diversity simultaneously. It’s really a paradox: we are all the same and yet all unique. This perspective is challenging in a modern world where some people are empowered and some are not, a world that is filled with division and the separation of groups based on race, class, gender identity, political affiliation, etc. Our job as yoga practitioners, and human rights advocates, is embrace those differences and at the same time to see the same essence in everyone we meet. 

According to the Bhagavad Gita, one of the most essential texts of yoga, as we become more in tune with ourselves, we begin to experience that underlying connection with others. Lord Krishna, who is teaching Arjuna how to be a yogi, explains:

“As your mind becomes harmonized through yoga practices, you begin to see the Atman in all being and all beings in your Self; you see the same Self everywhere and in everything. Those who see me wherever they look and recognize everything as my manifestation, never again feel separate from me, nor I from them. Whoever becomes established in the all-pervading oneness and worships me abiding in all beings – however he may be living, that yogi lives in me. The yogi who perceives the essential oneness everywhere naturally feels the pleasure or pain of others as his or her own.” (6.29-32 translation by Swami Satchidananda).

Just seeing through the diversity of nature to experience the oneness of creation isn’t enough. Krishna is teaching us that once we go down that path, we will literally feel the pleasure and pain of others as our own. That’s the ultimate level of awareness – true connection. And that is the first step on the path to equality and human rights. If we feel intimately connected to others, then we automatically take care of them. But this can only happen if we understand our personal privilege and the perspective we are coming from, otherwise that concept of oneness can be used to avoid the harsh reality of human rights abuse and leave us complacent. This is called spiritual bypassing.

“Spiritual bypassing perpetuates the idea that the belief “we are one” is enough to create a reality where we are treated equally and as one. It is not. Spiritual bypassing permits the status quo to stay in place and teaches people that if you believe in something and have a good intent that is enough. It is not.” —Michelle Cassandra Johnson

Those of us in positions of power and authority can use our yoga practice to reveal hidden truths in our own behavior and attitude—things we may not want to see in ourselves. The practice of svadhyaya, or reflection, is an essential part of yoga. In svadhyaya we attempt to witness the workings of our own mind, to see our ego and its prejudices. In the self-reflection that our practice brings, we can consider this question: Are my efforts reinforcing the status quo or is my practice inspiring me to actively work on achieving human rights for all? 

Regarding ableism specifically, yoga teachers can reflect on whether unknowingly they may be teaching yoga in a discriminatory way. For example, am I teaching in a wheelchair-accessible space? Am I teaching in a way that values physical ability as superior or advanced? Am I giving all students the same respect, attention, and kindness regardless of ability? Are my offerings advancing equality in the yoga community? What can I do to cultivate svadhaya in myself, in my students, and in my peers?

We can also examine our language: Am I reinforcing stereotypes that I am also the victim of? For example, do I hide my own physical challenges out of an effort to seem like the perfect yogi, rather than honestly share with students about where I am at? Can I examine the culture of the yoga studios I teach or visit to see if they are in line with my own beliefs? Do the social media accounts I follow make me feel better about myself or reinforce insecurity and self-doubt? 

For those of us who are oppressed or lacking in human rights, we can use our yoga practice as a source of power and healing. That means seeking out supportive yoga communities that don’t make us feel less than but rather help to lift us up. In this way, we can use yoga as self-care and as a source of empowerment. According to Audre Lorde:

“Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”

This paradox of unity and diversity is at the heart of yoga and at the heart of human rights. With practice, self-awareness, and action, we can deepen our experience of yoga, connecting with our true self and simultaneously begin to honestly and openly address human rights and discrimination of all kinds.



Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook and Twitter ° To order Yoga for Healthy Aging: A Guide to Lifelong Well-Being, go to Amazon, Shambhala, Indie Bound or your local bookstore. For this month only, you can buy our e-book for only $2.99 on Kindle, Nook, Apple, Kobo, and Books-A-Million!

Follow Jivana Heyman on Facebook and Instagram and see Jivana's Workshops and Trainings for upcoming workshops and trainings. For information on Accessible Yoga, see accessibleyoga.org and follow Accessible Yoga on Facebook and Instagram.

Video of the Week: Standing One Legged King Pigeon Pose

Standing One Legged King Pigeon pose is a good way to improve balance and also stretch your hips. It resembles the forward folding version of the classic pose, but you do the pose standing upright. If desired, you can do this balance pose close to a wall. If your balance is poor, you should watch the video through once to make sure it is appropriate for you to try. 

For this month only, you can buy our e-book for only $2.99 on Kindle, Nook, Apple, Kobo, and Books-A-Million!

Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook and Twitter ° To order Yoga for Healthy Aging: A Guide to Lifelong Well-Being, go to Amazon, Shambhala, Indie Bound or your local bookstore.

Follow Baxter Bell, MD on YouTube, Facebook, and Instagram. For upcoming workshops and retreats see Baxter's Workshops and for info on Baxter see baxterbell.com.  

Friday Q&A: Hanging Upside Down

The Monkeys in the Jungle by Henri Rousseau

Q: Recently I had an X-ray of my spine to see what was causing my low back pain. I already knew I had scoliosis in my lumbar spine (see Scoliosis and Yoga: The Big Picture) but I was wondering what was going on with my lumbar joints. Sure enough, I had serious arthritis in my two lowest lumbar joints. While discussing this with my chiropractor, who is also a yoga practitioner, I asked if hanging upside down would be good for me. (By hanging upside down, I mean supporting my pelvis in a full inverted position, not just hanging in Downward-Facing Dog from a strap around some door knobs.) I knew that reversing gravity for the spine can make space there and provide relief. And this could be a really good counter activity to do after my gardening sessions. She said she thought that was an excellent idea! But when I asked her about preferred equipment for this, she said she had no idea. 

So today I'm asking for your help, dear readers! For once, you get to answer the question. What is your recommendation (and feel free to use brand names, etc.) for a simple setup I can use in my house so I can hang upside down on a regular basis. Yes, I know about the Iyengar-style wall ropes, but I'm not sure I want anything that elaborate (though I wouldn't mind hearing about where to get those). Isn't there some kind of pelvic sling you can attach to a wall? (I'm not looking for anything where I hang from my ankles, by the way.)

Leave replies in the comments section or email me at nina at wanderingmind dot com.

Thanks so much,

Nina



For this month only, you can buy our e-book for only $2.99 on Kindle, Nook, Apple, Kobo, and Books-A-Million!

Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook and Twitter ° To order Yoga for Healthy Aging: A Guide to Lifelong Well-Being, go to Amazon, Shambhala, Indie Bound or your local bookstore. 

Yoga for Healthy Aging E-Book Available for $2.99 for the Month of November!

by Nina

I am so excited to announce that for the month of November, the e-book edition of Yoga for Healthy Aging: A Guide to Lifelong Well-Being will be available for only $2.99 on Kindle, Nook, Apple, Kobo, and Books-A-Million! This is an amazing price for a book that is sure to be a well-used resource for you for many years to come.

This price of $2.99 for US only. If you are in another country, you'll have to purchase it through your local e-book provider. Check where you usually buy your e-books to see what the discounted price is for your country. The discounted price for everyone will only be available until Dec. 2.  

For a review of our book that we feel shows a good understanding of what the purpose of our book is and what it is all about, see Book Review: Yoga for Healthy Aging by Charlotte Bell.


Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook and Twitter ° To order Yoga for Healthy Aging: A Guide to Lifelong Well-Being, go to Amazon, Shambhala, Indie Bound or your local bookstore.


For information about Nina's upcoming book signings and other activities, see Nina's Workshops, Book Signings, and Books.