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Chapter 2

An Exploration of the Holistic Yoga Approach and How It Can Help

Because on the surface both Parkinson’s and MS present in such a physical way, it is hard not to see that making improvements to physical wellbeing is all that is needed to make a huge difference to someone with these diagnoses. And yet yoga, more than any other therapy, is bound up in the concept of what makes up a human being, and what makes that being whole.

Although Western medicine separates out the systems of the body, and seeks to find the origin of the disease process to find a cure, Eastern medicine looks at a much more subtle construct of health and wellbeing, the energy or life force known as prana, which acts as a blueprint for the whole organism. Understanding how that energy flows and manifests as prana vayu to sustain the organism, or becomes stagnant or restricted, forms a different view of ill health.

There are several models that serve as a means of looking at the qualities of each individual and therefore the kind of yoga practices that will be useful. The model of the three gunas (qualities of nature) describes states of inertia, activity or balance. Ayurveda uses the system of doshas to categorise each person and to find the treatment that will best work with their type. Yoga has the principle of Pancha kosha, an overview of the different parts of a human being from the physical to the spiritual, and even more subtle is the chakra system underlying all.

Although I do not go into great detail about all of these systems, we can use them to understand these diseases from a yoga viewpoint, and to help guide the practices that will support the human being into a state of wellness.

Only in the last century have psychologists, and neural scientists, come to see that the emotional, social interactiveness and thought processes of the individual have a great bearing on overall health, stress levels and happiness, and that these influence the body’s ability to heal itself.

In the next section we will see what yoga can do, and how the different models can inform therapeutic practice.

Looking after the whole person

When assessing the needs of individuals with a view to setting a yoga practice, for any health problem, the Pancha kosha (maya) model gives us a simple way of observing the person from five different aspects:

•Annamaya kosha, the physical body, supporting the needs of the body, its functions and activities.

•Pranamaya kosha, the energy body. Although we access prana (life force) from other sources (our food, water and environment), focusing on the ability to breath well is vital, as the pranic body provides a ‘blueprint’ to support the physical systems.

•Manomaya kosha, the mental/emotional body. The lower mental function operates here, including all our emotional ups and downs. Working at this level is key to enhancing wellbeing, and bringing about mental clarity and a calm emotional disposition.

•Vijnanamaya kosha, the wisdom body, engages the intellect and higher faculties of the mind. In this place we see from a different point of view, understand things differently, adapt and learn.

•Anandamaya kosha, often referred to as the ‘bliss body’, needs to be nourished adequately. In lay terms, this refers to our ability to find contentment and inspiration.

The koshas do not really operate as layers; they are imprinted into the fabric of our being and work together to form the whole. They are interdependent.

In people with limited mobility, one would think that the physical level is the one demanding most attention, but this is not the case. Practices that support and balance the emotional and mental faculties will have just as much, if not more, benefit to the overall health and wellbeing of the person.

Some examples of practices and activities that can nourish and balance each kosha level are shown below.

How we might support and balance the koshas

Annamaya kosha, the physical body

Asana, mobility, stability and awareness

It has been shown that exercise is paramount for people with Parkinson’s. Rather than being limited by the disease, staying active and working the body keeps people active and independent for longer, giving a better quality of life and enabling people to engage in normal, everyday life for much longer than was previously thought possible. In people with MS, mobility, strength and stability are important in combating the effects of the disease. Yoga is excellent in that it is easily adaptable and can offer a variety of useful practices. Asanas have a positive effect throughout all of the systems of the body as well as on the musculoskeletal system. Asana practice improves digestion, elimination, heart and lung function, and impacts the brain, nervous and endocrine activity in a positive way.

Firmly in the field of Annamaya, in relation to the physical body for people with Parkinson’s is the issue of posture, which often becomes stooped, or Pisa syndrome can develop, where the person leans to one side. A study by Dr Karen Doherty et al. (2013) said that:

While most of the people who took part in our study had difficulty correcting their posture by themselves, few actually had permanent changes in their spine… The changes we saw tended to involve muscles and joints becoming stuck in the wrong position – like bent knees or a tilted pelvis. This suggests that people may benefit from non-surgical interventions like physiotherapy.

In MS the issue may be more one of steadiness and balance.

In yoga, asana practice can go a long way in helping towards better posture and increased awareness to help strengthen the core muscles, proprioception and balance, thus avoiding the aches and pains that come with poor posture.

There are other therapies that may help. It is acknowledged that some complementary therapies are helpful for Parkinson’s – aromatherapy, reflexology, massage, chiropractic, osteopathy and physiotherapy, Conductive Education, as well as walking and swimming are all ways of staying active and stimulated.

Supporting Annamaya with diet

The digestive system in both Parkinson’s and MS can become sluggish as the muscular action of the gut is affected, which can cause poor absorption and constipation. Moving and stretching can help with this.

Diet and Parkinson’s

Proteins can interfere with the way Levodopa is used by the body, so it is essential that dietary recommendations are followed, at the same time getting all the nutritional elements needed for health. The Parkinson’s UK booklet on diet refers to research where people reduced the amount of daytime protein they ate to improve their response to Levodopa, which can help some people. A protein redistribution diet is sometimes suggested where most protein is eaten in the evening.

It is important, however, to keep eating protein as it is an essential part of nutrition, and is vital to help the body to renew itself and fight infection. Reducing protein may cause dangerous weight loss. Following general guidelines for keeping weight steady, eating plenty of fibre, fruit and vegetables, and drinking adequate amounts of water are all advised.

Diet and multiple sclerosis

According to the MS Trust:

Whether it is possible to influence multiple sclerosis through diet and dietary supplements is a controversial topic. There is much information available in books, magazines and on the web, much of it contradictory. Opinions range from denying any evidence of benefit to suggesting that MS can effectively be cured by particular diets.

It goes on to suggest that, for many people with MS, managing what they eat offers the possibility of a sense of control in dealing with their condition. Poor diet and nutrition can also worsen existing symptoms such as fatigue and weakness. Awareness of diet also offers the opportunity to promote general health and wellbeing, which may be even more important following a diagnosis of MS.

It seems that fats and vitamin D have a part to play, although it remains a controversial subject, with many conflicting views and research, but exploring for yourself what diet works best for you would be an important way of supporting Annamaya.

Pranamaya kosha, the energy body

Breathing exercises and Pranayama

If there is no energy to draw on, we get pulled into a negative spiral: no energy – no motivation – begin to feel weak – can’t engage in activity – feel self-conscious and lack confidence – life becomes limited and the whole cycle starts again. If the lungs aren’t functioning well, nor is the heart or the circulation, and we become even more depleted in energy. Breathing practices not only bring improvement to the health of these organs but will also lift overall energy levels and improve mental outlook. However physically limited one might be, working with the breath is always possible.

Other activities such as singing are helpful to focus on controlling the breath and to keep lungs healthy.

Manomaya kosha, the mental body

Mind/emotions: deep relaxation, Pratyahara, yoga nidra, visualisation, affirmation, and meditation help in staying positive and keeping calm

A diagnosis of Parkinson’s or MS may bring with it depression. Feelings of helplessness, hopelessness and low self-worth may follow. Meditation practices can begin to re-set expectations and bring a quality of aliveness that is felt when we ‘live in the moment’. At this level of being we are able to use yoga practices to find balance, and to move towards positive thinking and deal with negative thoughts and fears.

Anxiety is commonly found in people with Parkinson’s and MS, and yoga offers many practices to change this; breathing, relaxation and meditation can all help to re-balance the nervous system and implement positive changes.

If you are working one-to-one, you may be able to provide a resource by just listening. When the medical regime presents problems, and medication is not working as expected, people with Parkinson’s will often feel angry and frustrated. These are feelings that may spill over into their family circle, or that they want to hide from the people who care for them, in order not to burden them further. At such times, someone outside of their caring team who has no other involvement may be those to whom it is safe to express these emotions – expression is healthier than repression.

Vijnanamaya kosha, the wisdom body

Wisdom and function of the higher mind and intellect

When we are open to learning, and able to reflect on life, lessons are learned and positive changes can be made. We might find inspiration in many places. When life brings challenges, we have an opportunity to review what works and what doesn’t. Day-to-day living itself will be a challenge for many with Parkinson’s or neurological problems, but if we remove the filters of fear and depression, there may be many helpful things to learn. In the yoga tradition many would turn to the ancient texts of the Bhagavad Gita and Patanjali’s Sutras for guidance. There are equivalents in other traditions, but it may be that we are inspired by friends, health workers, classmates, internet forums, educational films as well as many other sources.

Keeping an open mind is essential.

Anandamaya kosha, the ‘bliss body’

Finding inspiration, remembering to play, finding the ah! moments

Connecting with a part of yourself that takes you into a different realm, where you can experience spiritual connection and upliftment, is profound and beautiful. Rather than stumbling across these moments, we can actively seek them. Finding beauty and awe links us to a part of our being that is fulfilling like no other. Watch the sea, see the sunset, look at the stars, sit in a cathedral – lift out of the everyday.

It is essential that first and foremost we offer yoga within the guidance of Patanjali and Ahimsa (non-violence), working with compassion and understanding.

How Patanjali’s Sutras guide the therapeutic approach

Patanjali’s Sutras offer an underpinning of philosophy for therapeutic yoga. In Sutra 1.2, Chitta vrtti nirodhah, restraint of the modifications of the mind, Patanjali infers that the unadulterated mind state is pure and clear. Our thoughts – all of them – are disturbances. To bring them into a peaceful state is a challenge for even the healthiest individual. How much more challenging then when Parkinson’s or MS is diagnosed.

Even the word ‘yoga’ has a definition of unity, and implies balance, harmonising the body and mind, inner and outer. Yoga is all about changing the world within, bringing new perspectives. Rather than enlightenment being a saintly state of bliss, we can gain some kind of liberation by freeing ourselves from fear and limitations imposed by our own thinking and beliefs. Reconnecting with the true self, and understanding who, how and what that is brings a very different viewpoint of life, one that is not conditional on the physical state. And when we are in balance, follow Sutra 1.3, Tada drasthu svarupe vasthanam, then the self/seer abides in its own nature. This leads to self-realisation.

However, we are not in a calm, balanced, clear place most of the time. We are pulled and pushed by the activities of the mind and in a reactive state of being. Patanjali goes on to describe these modifications, the vrtti, some of which bring suffering and some joy. In order to find balance, Patanjali urges practice. With these Sutras in mind, we can see that when illness is chronic and prolonged, more determination is needed to overcome distractions.

Distractions are listed in Sutra 1.30 – they are obstacles to progress. Vyahhi styana samshaya pramada alasya avirati bhranti-darshana alabdha-bhumikatva anavasthitatva chitta vikshepa te antarayah – vyahhi, disease is the first obstacle, followed by dullness, carelessness, laziness, sensuality, false perception, failure to reach firm ground, and slipping back from progress made, complete the list.

In Sutra 1.31, duhkha daurmanasya angam-ejayatva shvasa prashvasah vikshepa sahabhuva, distress, despair, trembling of the body and disturbed breathing are identified.

All of these would be easily identifiable in a person with Parkinson’s or MS. The disease can overtake life completely so that the idea of a true self existing and being able to connect with that part is left far behind. Although there is desire to ease or even overcome some of the physical symptoms of the disease, there is also a need for the individual to be preserved and not lost in the disease process. Woven into yoga sessions should be the underpinning philosophy that the self dwells within and can be nurtured, recognised and present. Thus the quality of life is enhanced.

Patanjali goes on to say that focused practice is the best way to overcome distractions. Perseverance, practice and focus can all be encouraged within the yoga practices planned. We need to motivate, encourage, educate and inform, so that students feel supported in moving forward. It is in this area that we can offer practice sheets, describing 10–20 minute sessions to be done at home, to engage regular practice.

In Sutra 1.33, Maitri karuna mudita upekshanam sukha duhka punya apunya vishayanam bhavanatah chitta prasadanam, Patanjali states that by being friendly and compassionate and not focusing on the negatives, the mind is able to become calm.

In recent years we have seen studies in the field of neurophysiology that show that these attitudes help in healing stress and trauma, the part of the nervous system responsive to the social environment and relationships. The vagus nerve and the enteric nervous system respond to friendliness, compassion, warmth and love, which bring about positive changes in health, and the human being can move towards homeostasis (Porges 2011).

It is important to encourage this attitude both as a leader of a group and among the group members themselves. My observation in working with small groups, especially those connected to a charitable network where there is social interaction as well as education, is that by care, consideration and inclusiveness, one can bring about a sense of belonging and wellbeing that supports the progress made in other areas of yoga practice.

Patanjali goes on to offer breathing, awareness/mindfulness and meditation as practices that lessen the power of negative, hurtful, traumatic memories and experiences, and lead to a better quality of life.

In the second part of Patanjali’s Sutras, 2.3–9, the five obstacles – kleshas – are described, and we are reminded that they are ever-present. These are ignorance, egoism, attachment, hatred and clinging to bodily life. Ignorance in this instance is not just a lack of knowledge or education, but not being able to see the truth. When we are caught up in suffering, our ability to recognise what is real diminishes.

Do our students want to engage in this search for the truth? As with yoga itself, and in life in general, some people are drawn to be seekers and others follow a different path. If this concept is at the heart of our teaching, I believe the quality and vibration of that message will get through. In many people, illness causes introspection and leads them to question the things in life of real value, to prioritise differently, to value life experiences differently. This, in its essence, is therapeutic.

As yoga teachers, we are encouraged to offer a spread of practices following the guidelines set by Patanjali, known commonly as ‘The Eight Limbs of Yoga’: Yama, Niyama, Asana, Pranayama, Prtyahara, Dharana, Dhyana and Samadhi. In planning a balanced yoga session, these offer a framework of underpinning ethics, moral standpoint, practices and progression.

Patanjali’s ‘Eight Limbs’ offer the model defining yoga practice in working towards the goal of a healthy contented life.

Yama and Niyama underpin our teaching and guide our conduct and attitudes.

Yama is usually translated as restraints, which govern our conduct towards both ourselves and towards others:

•Ahimsa is the refusal of violence, or non-harming.

•Asteya is the refusal of stealing.

•Aparigraha is the refusal of covetousness.

•Satya is truthfulness.

•Brahmacharya is continence.

This group of rules guides us to respect and honour ourselves and others, to show our acknowledgment that there is a oneness in life, doing unto others as you would have done to yourself.

Niyama translates as observances:

•Saucha is purity.

•Tapas is austerity.

•Samtosa is contentment.

•Svadhyaya is self-study.

•Isvara pranidhana is devotion to the divine.

This group of rules offers guidance on how to conduct oneself and one’s thoughts to promote balance and happiness.

Asana offers a range of postures that are specifically tailored to the needs of the student and their capabilities. In asana practice we can improve balance, strengthen muscles and joint mobility, improve circulation and build overall confidence.

Pranayama offers suitable practices that improve oxygen intake and the efficiency and health of the lungs, thus keeping away infections.

Pratyahara is a key practice in aiding physical relaxation and offering an opportunity for inner awareness and inner stillness, bringing an experience of the self, with senses withdrawn.

Dharana offers training to focus concentration and to make progress towards meditation, which is helpful in daily living as we engage the nervous system and brain function.

Dyana is meditation. Although there may not be an opportunity to offer this as a practice within the time allowed in a Yoga Therapy group, students can be encouraged to go to a specialist practice group or to practise at home.

Samadhi is a personal experience that would be beyond the remit of the average therapy class.

Guidance for dealing with negative thinking is given in 2.33 and 2.34. When negative thoughts are troubling, think the opposite way – Pratipaksha Bhavana. We can engage with this in therapeutic yoga by offering positive ideas and thinking even in a small way.

Parkinson’s disease, multiple sclerosis and the chakra system

There is a point of view that the pranic flow is the origin of health, and when that flow becomes disturbed, ill health follows. The disturbance of energy may begin long before the disease is identified. Many yoga teachers are familiar with the subtle energy system of the chakras, and if we consider what is happening at the subtle energy level, we can see the way that Parkinson’s disease and similarly MS show energy imbalance.

The chakras are distribution centres, sending energy out to all the different kosha (levels), through the nervous system, endocrine system and organs of the body, giving us a 3D model. In yoga terminology this happens through the nadis and vayus. We can see how this would impact on the functioning of the whole if it is out of balance.

Just how disturbance manifests in Parkinson’s or MS is summarised over the next few pages. This is a projected general analysis as each individual has their own unique pattern.

The root chakra: Muladhara

What we can observe in Parkinson’s and MS is that communication between the brain and body is not functioning. As this affects mobility and ability to control movements, we can expect a severe disruption in Muladhara chakra. So we have instability, loss of balance and disrupted function of walking. Postures can be offered to stabilise, strengthen and energise Muladhara. It is unlikely that there would be a permanent change. It has to be worked regularly to improve quality of life.

On an emotional level, there will be a degree of fear held here that will block energy flow, fear of falling and fear of the condition itself.

The sacral chakra: Swadhisthana

Dopamine is responsible for the experience of pleasure as well as being vital in transmitting messages to the muscles. It is here in Swadhisthana that we find the link into ‘desire’; this can be over-stimulated by the medication treating Parkinson’s. It can result in out-of-balance behaviour, or over-spending and seeking out pleasurable stimulation as desires intensify (medication is needed to keep this in balance).

As this centre is also to do with power, issues around loss of power will deplete the sacral centre. This may show in MS as mobility is affected and people with MS may become more reliant on others.

Freeing up the lower back, pelvis and hips can help keep the energy flowing.

The solar plexus chakra: Manipura

This is the chakra associated with self-confidence and being comfortable with our own identity as well as linking with the process of digestion. A diagnosis of Parkinson’s or MS can really knock self-esteem and self-confidence; there is a loss of sense of self and it is difficult to ‘digest’ the new situation. It is important when teaching to keep language positive and upbeat, giving encouragement and building week by week, encouraging the class to stay active, to mark achievements and to set goals that are achievable.

The heart chakra: Anahata

Although the Anahata chakra governs the physical heart and the function of respiration, it is here that we really engage with our emotions and where fear can block the energy flow – fear of the future, fear of losing oneself, losing touch with the true self, anxiety for just the everyday activities that become harder. As people become more dependent on others, relationships are tested. All of this will impact on Anahata. We may also lose love for ourselves, not liking what we are becoming.

The heart centre is linked to the thymus, a major organ of the immune system; this may be significant for MS, as it is a disease of the immune system.

The throat chakra: Vishuddhi

The throat is a command centre, governing to some extent the chakras below it. It is the centre of communication, governing speech and the voice.

In Parkinson’s the voice is often affected as the muscles weaken. People with Parkinson’s may not be able to vocalise their feelings, may be unable to express themselves, or may feel shame about their condition. Using the voice is both empowering and strengthening. Mantras may be useful in energising this centre, or singing, if a mantra is not appropriate – both will also ease and exercise the lungs. Using laughter to encourage is also helpful.

The brow chakra: Ajna

If we look at the physical aspects of this centre, we can see that it is here that the Parkinson’s malfunction originates – cells in the brain being unable to produce dopamine. So we have a disruption of the energy of Ajna. Ajna governs mental faculty, so here, again, we see loss of control. The brain is still able to function, but in some cases there is loss affecting memory and communication with other parts of the body, as motor function is lost.

In modern terms, we are told that it is possible to retrain our memory patterns, our nerve functions, owing to the plasticity of the brain. Understanding in this field is in the early days, but yoga provides a great opportunity to work the body/brain connection.

The crown chakra: Sahasrara

This is usually thought of as our spiritual connection. Each person often has a very personal experience of their own spiritual connection, and mostly this subject is outside of the remit of an hour-long class.

We cannot know each individual viewpoint without a deep conversation, but there are some difficulties in upholding a meditative practice. Disease, dullness, carelessness, laziness, false perception, failure to establish the practice, physical unsteadiness, distress, despair and disturbed breathing, these are all are obstacles to progress, as detailed by Patanjali in 1.30–31. However, if there is consistent application towards opening at this level, who knows what may be achieved?

Practices for working on the chakras can be found on pages 246–256.

The five vayus (the five movements or functions of prana)

From the yogic point of view the body is a collection of energy channels. The vayus describe physical flow and function within the systems of the body. This is seen in digestion and elimination, circulation of the blood, the electrical and chemical communication of the nervous system and the action of breathing. The biological workings of the body, its maintenance and repair, its constructive and destructive processes are directed by vayu. Vayu is the cosmic life force or bio energy that creates these channels.

We have five types of prana in the body: prana, apana, vyana, udana and samana.

•Prana vayu flow is inwards and upward. It nourishes the brain and the eyes and governs reception of all things: food, air, senses and thoughts. This is the fundamental energy in the body, and directs and feeds into the four other vayus. Inhaling is the most obvious action of prana.

•Apana vayu energy pervades the lower abdomen. The flow of apana vayu is downwards and out, and its energy nourishes the organs of digestion, reproduction and elimination. Apana vayu governs the elimination of all substances from the body: carbon monoxide, urine, stools, etc.

•Vyana vayu is situated in the heart and lungs and flows throughout the entire body. The flow of vyana vayu moves from inside to outside. It governs the circulation of all substances throughout the body, and assists the other vayus with their functions. We see its action in the circulation of blood and the peripheral nervous system.

•Udana vayu has a circular flow around the neck and head. It functions to ‘hold us up’ and governs speech, self-expression and growth.

•Samana vayu is situated in the abdomen with its energy centred in the navel. The flow of samana vayu moves from outside to inside. It governs the digestion and assimilation of all substances: food, air, experiences, emotions and thoughts.

In any diseased state these energies are out of balance, and the life force is not flowing. Yoga asana seeks to bring balance and flow in these vital forces. Prana and apana are the major forces, prana supporting and sustaining life and therefore supporting all of the others, and apana, energy leaving the body, is also essential for health. If apana is not flowing effectively, we suffer from congestive conditions, poor breathing, sluggish digestion, constipation and low-energy states.

Because of the individuality of the disease process, the effect on the vayu may be seen differently in each person. In general, in Parkinson’s one would assume that udana, the upward-moving energy, supporting thinking and the brain, speech and self-expression, would be depleted. But as in any illness it is best to work on balancing the whole and to strengthen the whole, rather than focusing on just one element.

Yoga Therapy

There are many different ways to deliver Yoga Therapy, and some will work in a traditional way that will include Ayurveda treatments. As it takes many years to train in Ayurveda medicine, the methods of Yoga Therapy offered here seek to bring improvement in the health and wellbeing of people with MS and Parkinson’s for their common symptoms and to improve their quality of life, without the specialist Ayurvedic approach.

Yoga Therapy is at its most effective when it is tailored for each individual. A student’s needs may vary, as there may be multiple health issues that need to be taken into consideration in planning practices. Even when working with a small ‘therapy’ group, each individual must be evaluated and considered, and contraindications for the individual taken into account. Before enrolling anyone into a specialist class, it is essential to take a full medical history. With both Parkinson’s and MS, people often reach a stage of immobility and may not be able to attend a class that includes asana. Working one-to-one is more suitable for these people, and breathing, meditation and working with the body, even in a small way, may contribute to that person’s quality of life.

The case for creative experimental modification of asana

When building a therapeutic practice, there should be considerations for the actions that we wish to implement. For example, postures that stretch the front of the body are often cited as being beneficial for ailments of the digestive tract. I have seen the Wheel Pose (Upward Bow, Chakrasana), Bow Pose (Dhanurasana) and Dynamic Bow Pose quoted as beneficial for diabetes, and the internet is full of ‘this practice is beneficial for this ailment’. If we are working with vulnerable people, we need to exert caution and begin to question ‘why?’ Many postures are for adepts, which would take many years of practice to accomplish. Students and people coming for Yoga Therapy are not adepts; they are often weak, immobile and ill. So we have to find ways of applying the therapeutic principle, and adapting the asana so that the therapeutic action can be applied.

We may be looking for optimising mobility or building strength and stamina, stretching muscles, improving alignment and posture, relaxing and relieving physical tension, relieving stress, and improving the internal functions.

Although in this book there are many ideas for modifying practices for these particular student groups, in reality your students will be the ones to teach you how to help them. Only they can say where their pain is, what their limitations are, and what other problems they have that need to be taken into account.