Yoga Now Standard Treatment for Vets with PTSD

Yoga's not usually the first thing that springs to mind when thinking about treatment for post traumatic stress disorder in veterans. But from the Veterans Administration to the Pentagon, yoga classes are becoming not just commonplace, but in some rehabilitation programs mandatory.

One of the places in the forefront of change is the Newington Yoga Center, in Newington, Connecticut.

About 20 veterans train to become yoga teachers. Suzanne Manafort of the Veterans Yoga Project, said what began as a small project has burgeoned into programs across the country. Manafort taught yoga for years before using it as a treatment for PTSD. She said she had no idea she might need to make adjustments to her teaching, until she made mistakes.

"Touching is a mistake. In yoga classes we touch all the time. But to somebody whose been sexually assaulted that's a huge violation. Walking behind them is a huge mistake because it feels like they have to pay attention to what's going on in the room instead of just practicing their yoga practice," Manafort said.

She said ultimately it was veterans themselves that guided her, in some cases just by the courage it took simply to stay in class.

"Some of the men and women that I work with are Vietnam Veterans so they've been at home suffering for 40 years," said Manafort. "And when they come into this treatment program and they're told they have to do yoga, 'they're like are you kidding me?'"

"I thought it was a joke," said Vietnam veteran Paul Gryzwinski. "And I remembered actually laughing out loud and they said no we're really not kidding you're going to be going to yoga."

Gryzwinski is training to teach yoga to veterans. Many years after returning from the war, PTSD hit him hard. He ended up turning to the VA. Where he first encountered yoga.

"And I just thought of myself in like, tights with you know a bunch of women. And I know that sounds sexist — and I'm not, so forgive me — but it was such an alien concept to me," Gryzwinski said with a chuckle.

And Gryswinski's early misperceptions are one reason that Dan libby, a co-founder of the Veterans Yoga Project, said the 12 week yoga training for treating vets with PTSD tries to strip all the new-agey stuff out.

"We really emphasize, 'leave all the Sanskrit names at home, right. Leave the candles at home, don't talk about you know moonbeams and chakras and all these things,'" he said. "It's really just about learning about your body and your experience; learning to breathe."

Lt. Col Melinda Morgan deployed right after 9-11 and started teaching yoga to those who had served and those who were preparing to go to Afghanistan.

"So I started teaching veterans 10 years ago and one of those veterans that I taught became an instructor himself. And so in 2007 when he was in Iraq and I was in another location, he writes me a note that said, 'I have to teach yoga and I don't think I can.' So I'm like, 'yes you can.' I wrote it down all of the poses, emailed it to him and helped him on his way to become a certified teacher," Morgan said.

Today, Morgan teaches at the Pentagon, and she said classes once sparsely attended are now full every day. But despite an increased demand for yoga paired with a growing number of alternative treatment programs in the military and the VA, there's scant hard science about why yoga or most of the other alternative programs work.

Yoga instructor Dan Libby hopes the government does some studies soon, because without more data, returning troops won't take the programs seriously.

This article originally appeared on pri.org
Host Marco Werman
Reporter Susan Kaplan

Links

• VetsYoga
• Veterans Yoga Project
• Give Back Yoga

Yoga Therapy: Why Doctors Are Prescribing The Ancient Practice

In 2011, Jacquelyn Jackson had the most traumatizing year of her life. On a beautiful morning in Tucson, she was just 25 feet away when her former boss, Congresswoman Gabrielle Giffords, and 18 others were shot in a grocery store parking lot. In the weeks that followed, as Jackson began suffering symptoms of post-traumatic stress disorder (including chronic anxiety and difficulty sleeping), she turned to a psychotherapist. The sessions helped “tremendously,” she says but 11 months later, when her seemingly healthy younger brother died suddenly from a brain tumor. “the trauma was so great I felt like I needed something more.”

Desperate, Jackson looked online for support and stumbled upon yoga therapy, an emerging treatment for people struggling with anxiety, grief, and trauma. Long practiced in India, yoga therapy was introduced in the United States some three decades ago but has begun gaining popularity only in the past five years or so. (Membership in the International Association of Yoga Therapists [IAYT] has quadrupled since 2004, to about 3,200, and next year the IAYT plans to begin accrediting yoga schools to offer a standardized certification program.)

“It’s not just postures,” says yoga therapist Janice Gates. “We use all the tools of yoga — breath work, sound, visualization, and meditation — and tailor them to a client’s specific health condition.” One of Gates’s clients was a woman in her 40s who was experiencing serious depression and anxiety but couldn’t tolerate psychiatric medication. While a doctor oversaw the medical issues, Gates worked with the client weekly to manage her moods. On days when she was anxious, Gates led her through exercises like standing poses and forward bends (to help her feel more grounded) and exhalation breath work (to calm her down). When the woman was depressed, she did back bends and inhalation exercises, designed to give her energy. Six months later, the woman’s crippling dark moods, once a thrice-weekly occurrence, now overtake her only a few times each month. With her newfound energy — and time — she’s teaching art classes to children.

Though research on the efficacy of yoga therapy is ongoing, traditional doctors are taking notice — and finding it, in some cases, to be a valuable complement to the work they’re already doing. “Yoga therapy can be extremely helpful for people who need a way to work through what they’re experiencing, not just in their minds but in their bodies,” says psychotherapist Jack Obedzinski, MD, of Corte Madera, California. “Often, it allows my patients to experience a feeling of calm in a way they couldn’t in talk therapy.” And, he says, this calmness can bring more clarity and awareness to their traditional sessions.

For Jackson, one-on-one yoga appointments with Amy Weintraub, a pioneer in the field and author of Yoga for Depression, proved transformative. In their first session, Jackson “was practically hyperventilating with anxiety,” says Weintraub, who created a program that included “stair-step” breathing, building up to deeper and deeper breaths. “What the yoga did was provide a slow, gradual path to help her manage her moods and not immediately react when grief arose.” After just a few sessions, Jackson no longer used medication to help her sleep at night. “Working with Amy was like doing emotional Roto-Rooter-ing,” she says. “I had so much stress in my body, and she was able to help dislodge it — and clear it out.”

This article originally appeared on huffingtonpost.com and was written By Laura Hilgers.

Check out our UPCOMING MENTAL WELLNESS WORKSHOPS with Shari Arial: Yoga for Anxiety, Stress & Trauma.

Yoga for anxiety and depression.

Studies suggest that this practice modulates the stress response.

Since the 1970s, meditation and other stress-reduction techniques have been studied as possible treatments for depression and anxiety. One such practice, yoga, has received less attention in the medical literature, though it has become increasingly popular in recent decades. One national survey estimated, for example, that about 7.5% of U.S. adults had tried yoga at least once, and that nearly 4% practiced yoga in the previous year.

Yoga classes can vary from gentle and accommodating to strenuous and challenging; the choice of style tends to be based on physical ability and personal preference. Hatha yoga, the most common type of yoga practiced in the United States, combines three elements: physical poses, called asanas; controlled breathing practiced in conjunction with asanas; and a short period of deep relaxation or meditation.

Many of the studies evaluating yoga's therapeutic benefits have been small and poorly designed. However, a 2004 analysis found that, in recent decades, an increasing number have been randomized controlled trials — the most rigorous standard for proving efficacy.

Available reviews of a wide range of yoga practices suggest they can reduce the impact of exaggerated stress responses and may be helpful for both anxiety and depression. In this respect, yoga functions like other self-soothing techniques, such as meditation, relaxation, exercise, or even socializing with friends.

Taming the stress response

By reducing perceived stress and anxiety, yoga appears to modulate stress response systems. This, in turn, decreases physiological arousal — for example, reducing the heart rate, lowering blood pressure, and easing respiration. There is also evidence that yoga practices help increase heart rate variability, an indicator of the body's ability to respond to stress more flexibly.

A small but intriguing study further characterizes the effect of yoga on the stress response. In 2008, researchers at the University of Utah presented preliminary results from a study of varied participants' responses to pain. They note that people who have a poorly regulated response to stress are also more sensitive to pain. Their subjects were 12 experienced yoga practitioners, 14 people with fibromyalgia (a condition many researchers consider a stress-related illness that is characterized by hypersensitivity to pain), and 16 healthy volunteers.

When the three groups were subjected to more or less painful thumbnail pressure, the participants with fibromyalgia — as expected — perceived pain at lower pressure levels compared with the other subjects. Functional MRIs showed they also had the greatest activity in areas of the brain associated with the pain response. In contrast, the yoga practitioners had the highest pain tolerance and lowest pain-related brain activity during the MRI. The study underscores the value of techniques, such as yoga, that can help a person regulate their stress and, therefore, pain responses.

Improved mood and functioning

Questions remain about exactly how yoga works to improve mood, but preliminary evidence suggests its benefit is similar to that of exercise and relaxation techniques.

In a German study published in 2005, 24 women who described themselves as "emotionally distressed" took two 90-minute yoga classes a week for three months. Women in a control group maintained their normal activities and were asked not to begin an exercise or stress-reduction program during the study period.

Though not formally diagnosed with depression, all participants had experienced emotional distress for at least half of the previous 90 days. They were also one standard deviation above the population norm in scores for perceived stress (measured by the Cohen Perceived Stress Scale), anxiety (measured using the Spielberger State-Trait Anxiety Inventory), and depression (scored with the Profile of Mood States and the Center for Epidemiological Studies Depression Scale, or CES-D).

At the end of three months, women in the yoga group reported improvements in perceived stress, depression, anxiety, energy, fatigue, and well-being. Depression scores improved by 50%, anxiety scores by 30%, and overall well-being scores by 65%. Initial complaints of headaches, back pain, and poor sleep quality also resolved much more often in the yoga group than in the control group.

One uncontrolled, descriptive 2005 study examined the effects of a single yoga class for inpatients at a New Hampshire psychiatric hospital. The 113 participants included patients with bipolar disorder, major depression, and schizophrenia. After the class, average levels of tension, anxiety, depression, anger, hostility, and fatigue dropped significantly, as measured by the Profile of Mood States, a standard 65-item questionnaire that participants answered on their own before and after the class. Patients who chose to participate in additional classes experienced similar short-term positive effects.

Further controlled trials of yoga practice have demonstrated improvements in mood and quality of life for the elderly, people caring for patients with dementia, breast cancer survivors, and patients with epilepsy.

Benefits of controlled breathing

A type of controlled breathing with roots in traditional yoga shows promise in providing relief for depression. The program, called Sudarshan Kriya yoga (SKY), involves several types of cyclical breathing patterns, ranging from slow and calming to rapid and stimulating.

One study compared 30 minutes of SKY breathing, done six days a week, to bilateral electroconvulsive therapy and the tricyclic antidepressant imipramine in 45 people hospitalized for depression. After four weeks of treatment, 93% of those receiving electroconvulsive therapy, 73% of those taking imipramine, and 67% of those using the breathing technique had achieved remission.

Another study examined the effects of SKY on depressive symptoms in 60 alcohol-dependent men. After a week of a standard detoxification program at a mental health center in Bangalore, India, participants were randomly assigned to two weeks of SKY or a standard alcoholism treatment control. After the full three weeks, scores on a standard depression inventory dropped 75% in the SKY group, as compared with 60% in the standard treatment group. Levels of two stress hormones, cortisol and corticotropin, also dropped in the SKY group, but not in the control group. The authors suggest that SKY might be a beneficial treatment for depression in the early stages of recovery from alcoholism.

Potential help for PTSD

Since evidence suggests that yoga can tone down maladaptive nervous system arousal, researchers are exploring whether or not yoga can be a helpful practice for patients with post-traumatic stress disorder (PTSD).

One randomized controlled study examined the effects of yoga and a breathing program in disabled Australian Vietnam veterans diagnosed with severe PTSD. The veterans were heavy daily drinkers, and all were taking at least one antidepressant. The five-day course included breathing techniques (see above), yoga asanas, education about stress reduction, and guided meditation. Participants were evaluated at the beginning of the study using the Clinician Administered PTSD Scale (CAPS), which ranks symptom severity on an 80-point scale.

Six weeks after the study began, the yoga and breathing group had dropped their CAPS scores from averages of 57 (moderate to severe symptoms) to 42 (mild to moderate). These improvements persisted at a six-month follow-up. The control group, consisting of veterans on a waiting list, showed no improvement.

About 20% of war veterans who served in Afghanistan or Iraq suffer from PTSD, according to one estimate. Experts treating this population suggest that yoga can be a useful addition to the treatment program.

Researchers at the Walter Reed Army Medical Center in Washington, D.C., are offering a yogic method of deep relaxation to veterans returning from combat in Iraq and Afghanistan. Dr. Kristie Gore, a psychologist at Walter Reed, says the military hopes that yoga-based treatments will be more acceptable to the soldiers and less stigmatizing than traditional psychotherapy. The center now uses yoga and yogic relaxation in post-deployment PTSD awareness courses, and plans to conduct a controlled trial of their effectiveness in the future.

Cautions and encouragement

Although many forms of yoga practice are safe, some are strenuous and may not be appropriate for everyone. In particular, elderly patients or those with mobility problems may want to check first with a clinician before choosing yoga as a treatment option.

But for many patients dealing with depression, anxiety, or stress, yoga may be a very appealing way to better manage symptoms. Indeed, the scientific study of yoga demonstrates that mental and physical health are not just closely allied, but are essentially equivalent. The evidence is growing that yoga practice is a relatively low-risk, high-yield approach to improving overall health.

This article originally appeared on www.health.harvard.edu

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Wear and Care: Decrease Shoulder Pain and Build Strength with Yoga

Trish Jones knew trouble was brewing when her right shoulder began to throb during her favorite yoga class. The 29-year-old was no stranger to such pain. She had suffered from unstable shoulder joints for years. Her doctors call it “multidirectional instability,” but Jones refers to it as “having loose nuts and bolts.” So loose that in 1995 she had surgery to stabilize her left shoulder. Last summer, when pain began to gnaw at her other shoulder, she couldn’t shake the feeling that it was in trouble, too.

Still, Jones kept practicing Ashtanga three times a week at a studio near her home in Alexandria, Virginia, in hopes that the pain would work itself out. That is, until her right shoulder dislocated in Vasisthasana (Side Plank Pose). “Luckily, I knew exactly what happened, so I went out into the hall and popped it back in,” she says. Still, the incident served as a wake-up call. She knew the way to dodge a second surgery was to figure out how yoga could build up her shoulder strength without aggravating the instability.

After her injury, Jones switched to a restorative yoga practice and sought advice from yoga teachers, physical therapists, and doctors. Two weeks later, she was back at the studio. Under the close supervision of her teacher, she modified every pose in the Ashtanga primary and second series to spare her shoulder. They jettisoned all weight-bearing asanas, like Adho Mukha Svanasana (Downward-Facing Dog Pose) and Chaturanga Dandasana (Four-Limbed Staff Pose), and took an easy-does-it approach to shoulder openers, like Marichyasana I (Marichi’s Twist I.) “It was a much different practice than the typical first series,” Jones says, “but it wasn’t in my best interest to stop practicing altogether.”

Although Jones was eager to build strength in the damaged joint, she knew the only way to thwart another dislocation was to perfect her alignment. So she analyzed her shoulder position in every pose. To prevent rounding forward in the front of the shoulders, she started each asana by widening her collarbones. To protect the back of the joints, she made sure her upper back was engaged, with the bottom tips of the shoulder blades drawing together and down. Soon, these shoulder adjustments became a meditation in themselves.

As Jones found out, yoga can be a boon to the shoulders, but it can also be a bust. While an intense yoga class can leave your shoulder muscles a little sore the next day, you shouldn’t steamroll past any sharp or throbbing pain in the joint during or after practice. If your shoulders start to gripe whenever you roll out your mat, it’s time to tune in and figure out what’s going on before you do more harm than good. If your shoulders are free of trouble, don’t be overconfident: Now is the time to protect them from future injury. Either way, your shoulders will thank you, and your yoga practice will be stronger.

How it Works

Shoulder problems shouldn’t be shrugged off. In 2003 (the latest year for which numbers are available), nearly 14 million Americans visited a doctor complaining of a bum shoulder. Joint instability, like Jones’s, is one of the most common ailments. Others include impingements, rotator cuff tears, and arthritis.

Athletes often suffer disproportionately from shoulder injuries because the various repetitive movements stress the joints, says Jeffrey Abrams, an orthopedic surgeon in Princeton, New Jersey, and a spokesperson for the American Academy of Orthopedic Surgeons. “In other countries people play soccer, but here we like to ski and play golf and tennis, all of which are hard on the shoulders.” Jones is a typical example—when she was younger she played basketball and tennis and loved rock climbing. Now she puts her shoulders through their paces in Ashtanga.

But there’s another factor at play—the natural structure of the joint. “Shoulders are designed for mobility, not stability,” says Roger Cole, Ph.D., an Iyengar-certified teacher in Del Mar, California, who teaches workshops on shoulder safety. The mobility allows for an astonishing range of motion compared to that in the hips—if you have healthy shoulders you can move your arms forward, back, across the body, and in 360-degree circles. But the relatively loose joint relies on a delicate web of soft tissue to hold it together, which makes it more vulnerable to injury. (The soft tissue includes ligaments, which connect bone to bone; tendons, which attach muscle to bone; and muscles, which move and stabilize the bones.)

The main ball-and-socket joint is also quite shallow, adding to the flexibility but putting the joint at risk. Abrams likens it to a basketball sitting on top of a plunger. (The basketball is the head of the humerus, or upper arm bone, and the plunger is where it meets the scapula.) The rotation of a big ball on a little base makes the shoulder mobile.

When the soft tissue around the joint is strong and toned, the system works flawlessly. But factor in years of repetitive roundabout movements, like throwing a baseball, swimming, or even stretching the arms overhead in yoga, and shoulder ligaments can overstretch and lose elasticity, like worn rubber bands. Plus, as muscles age, they lose tone, making it even more likely that the ball will slip off the plunger at some point. The best way to stay out of a sling? Be diligent in your quest for proper alignment and build balanced strength around the joint to create stability.

Check your Alignment

Sounds easy enough, but here’s the hitch: Perfect shoulder placement in yoga can be elusive. For starters, unless you practice yoga in a mirror-lined room or have eyes in the back of your head, it’s tough to know what your shoulders are up to. To make matters worse, poor posture is habitual. If your shoulders slouch, slump, or cave all day long, you can’t help but bring a few bad habits into the yoga studio. “I see a lot of students with shoulders that slope, turn in, and jut forward,” says Mitchel Bleier, a senior certified Anusara Yoga teacher in Rochester, New York. “If those misalignments are maintained during yoga practice, especially during weight-bearing asanas, the risk of a shoulder injury goes up dramatically.”

Therefore, weight-bearing poses, such as inversions, require extra vigilance. Inversions are safe for the shoulders, Cole explains, but they are best performed with precise alignment.

The first step in understanding correct shoulder alignment is to start simply, by exploring Tadasana (Mountain Pose) and Urdhva Hastasana (Upward Salute). Here are Bleier’s alignment instructions for his students in Tadasana: First, lift your shoulders slightly so they line up with the base of your neck. Simultaneously, draw the heads of the arm bones back, toward the wall behind you. Keeping a slight curve in the back of your neck, draw your shoulder blades down toward your waist. Your shoulder blades should lie flat on your back, instead of winging out. Feel your chest rise, but resist the temptation to pinch your shoulder blades together—doing this will only compress your spine. Instead, keep the bottom tips of your shoulder blades pressing into your back and spreading. If you want to feel deliciously supported while doing this, try the Strap Jacket.

Reaching your arms overhead is a little more complex, but once you learn to do it correctly, you can apply the same principles in poses such as Downward-Facing Dog, Plank, or Adho Mukha Vrksasana (Handstand). Before you sweep your arms up into Urdhva Hastasana, it’s important to rotate your arm bones externally and move them down so the head of the arm bone is in the socket. This will strengthen the muscles on the back of the rotator cuff (the infraspinatus and teres minor), which are typically weaker than the front, and it will spare the supraspinatus, which can get pinched between the edge of the scapula and the head of the arm bone when the arms lift. If the tendon is pinched repeatedly, it wears and frays like a rope. Eventually, what begins as a mild irritation can progress to a severe injury, such as a tear.

Once your arms are straight overhead, you don’t have to pull your shoulders down quite so firmly, because that will inhibit your ability to reach up. To get the maximum reach safely, start in Urdhva Hastasana and spread your shoulder blades away from each other. As your shoulder blades wrap around toward the front of your rib cage, you should have more space to really lengthen up. The tops of your shoulders will lift slightly, which is OK. Just don’t let them bunch up by your ears. Now keep your shoulders in place and press your palms up toward the ceiling. Feel familiar? This is similar to the placement for Handstand.

Counteract Misalignment

Once you’ve mastered the ins and outs of proper alignment, you should be ready to build the strength to maintain it. And therein lies the rub. Done correctly, yoga poses strengthen the shoulders, but in order to do them correctly and maintain proper alignment, your shoulders have to be strong. Of any yoga pose, Chaturanga Dandasana (Four-Limbed Staff Pose); exemplifies this—if you’re not strong enough to keep your shoulders in their proper place, you leave yourself wide open to injury.

The most common misalignment is to collapse the chest and allow the heads of arm bones to drop forward toward the floor. You’ll know this is happening if your shoulder blades poke out instead of lying flat on your back, or if the fronts of your shoulders are sore the next day. This can strain the front of the rotator cuff and can also build strength unevenly, making the front of the rotator cuff stronger than the back. Over time this imbalance will pull the arm bone forward, contributing to a vicious cycle of misalignment.

To counteract this, start in Plank Pose, and as you move into Chaturanga Dandasana, see that the heads of the arm bones stay level with the elbows. Try not to let them dip down. (Practice at home in front of a mirror.) If they drop, you need to build more strength around the whole rotator cuff. To do that, practice Chaturanga with your knees on the floor and the Supine Sleepwalker Pose.

You can also practice what Cole calls the anti-Chaturanga, or Purvottanasana (Upward Plank Pose). “Purvottanasana stretches most of the muscles that Chaturanga strengthens and also strengthens opposing muscles,” Cole says. It’s one of the poses Trish Jones credits for helping her escape another shoulder surgery. “My rotator cuffs are stronger since I’ve adopted Purvottanasana into my practice,” she says. Finally, stretch the front of the chest by doing Setu Bandha Sarvangasana (Bridge Pose), Sarvangasana (Shoulderstand), and Matsyasana (Fish Pose).

Strengthen and Stabilize

To stabilize the joint and reinforce the rotator cuff, you’ll also need to focus on your supraspinatus, the muscle that helps you lift your arms out to the side. More specifically, the supraspinatus engages during the first 30 degrees of lifting the arms. Once your arms are shoulder level, your deltoids hold them up, which won’t strengthen the rotator cuffs. To strengthen the supraspinatus, practice standing poses where you reach the arms out, such as Trikonasana (Triangle Pose) and Virabhadrasana II (Warrior II). Hold the poses for five breaths and bring your arms down and back up between each pose.

Once you feel ready—meaning, the head of the arm bone isn’t slipping around and the joint is free of pain—toss a few weight-bearing poses into the mix. One of the best ways to build strength around the rotator cuff is to move slowly from Downward-Facing Dog out to Plank and back again. Just be careful not to let the upper back hyperextend and sink toward the floor in Downward-Facing Dog, which, according to Jean-Claude West, a kinesiologist and master manual therapist, can compress the joints. “Maintaining width in the upper back keeps the shoulder girdle active and the shoulder joints stable as you approach Plank,” he says.

Many yoga poses build arm strength by requiring you to push away from the floor—poses like Downward-Facing Dog, Handstand, and Urdhva Dhanurasana (Upward-Facing Bow Pose)—but few demand that your shoulder muscles pull against resistance, which is part of the reason the back of the rotator cuff gets so weak. One way to build oomph in the back of the shoulders is to engage in activities that require pulling, like swimming or even pull-ups, says Cole. On your yoga mat you can practice poses that require pressing the back of the shoulder joint against the floor, such as Jathara Parivartanasana (Revolved Abdomen Pose), or on a stable part of the body, such as the front leg in Parivrtta Parsvakonasana (Revolved Side Angle Pose).

Finally, create balanced flexibility by practicing poses that require an inward rotation of the shoulder, such as Gomukasana (Cow Face Pose), Marichyasana III (Marichi’s Twist III), and Parsvottanasana (Side Stretch Pose). “If you feel a pinching sensation when you rotate your shoulders inward, you are probably irritating a tendon or other connective tissue,” Cole says, “in which case, let the scapula wing out a little bit.” (Don’t practice these poses if you have a history of dislocation or shoulder instability.)

Although these practice tips are meant to keep your shoulders free of injury, when it comes to pain, it’s important to remember that there are no guarantees in yoga or in life. “Injuries can be a wonderful blessing; they offer us an opportunity to learn, to grow, and to be able to help others,” Bleier says. “We all have asymmetries in our bodies; there is no perfect way for the body to be, and if you have pain, it’s just your body’s way of asking you to examine what you’re doing.”

If anyone has learned that lesson, it’s been Trish Jones. “My shoulder pain has taught me to slow down and take my yoga practice back to basics,” she says. “The journey has been a humbling one, but I know I’m better for it.”

The Shoulder Strengthening Sequence

Supine Sleep Walker

This movement not only trains the heads of the arm bones to stay in the sockets during a wide range of movement but also builds well-rounded strength in the rotator cuff. Lie on your back with your knees bent and feet flat on the floor. Hold a yoga block horizontally between your hands and extend your arms up toward the ceiling. Draw the head of the arm bone into the shoulder socket so both shoulders press into the floor. Keeping the arms long, slowly lower the block overhead. As the block moves toward the floor, the backs of the shoulders may lift off the floor just slightly. But if the shoulders begin to bunch up by the ears, stop the block’s descent, realign the shoulders, and then continue to lower the block until it rests on the floor an arm’s length above your head. Now slowly lift the block back into the starting position while keeping your shoulders stable. Repeat up to 10 times.

Purvottanasana (Upward Plank Pose)

Purvottanasana counteracts the effects of Chaturanga by stretching the pectoralis major, pectoralis minor, and anterior deltoids. Sit in Dandasana (Staff Pose) with your hands several inches behind your hips and your fingers pointing forward. Bend your knees until you can place your feet flat on the floor. Exhale, press your feet and hands down into the floor, and lift your hips until you come into a tabletop position. Straighten your legs one by one and lift your hips still higher without squeezing your buttocks. Press the soles of your feet toward the floor. Lift your chest as high as you comfortably can. Keep the back of your neck long as you slowly drop your head back.

Jathara Parivartanasana (Revolved Abdomen Pose)

Lie on your back with your arms in a cactus position. Bring both feet off the floor and bend your knees until they are directly over your hips and your shins are parallel to the floor. Keeping your arms and shoulders pressing into the floor, exhale and lower your knees to the right. Don’t worry if your knees don’t come all the way to the floor. Instead, focus on keeping your shoulders grounded. Inhale and bring the legs back to center. Exhale to the opposite side. Repeat five times on each side. Keeping the back of your shoulders in firm contact with the floor strengthens the back of the rotator cuff, an area that’s commonly weak. This is generally safe to do if you’re recovering from injury because your body is well supported by the floor.

Standing Rotator Cuff Strengthener

This pose is similar to Jathara Parivartanasana but can be done from a standing position. Stand with your back to a wall. Raise your arms into a cactus position. Pull the heads of the arm bones back until you feel the upper back engage and press into the wall. Keep the tailbone tucked to avoid overarching the lumbar spine. Maintaining firm contact between your shoulders and the wall, and keeping your elbows bent at a 90-degree angle, slowly slide the arms up the wall. Ultimately, you may be able to touch your fingers overhead, but it may take time to get there. The key thing is to keep your shoulder blades flat against the wall. Repeat up to 10 times.

Strap Jacket

Getting the strap set up can be tricky the first time you do this pose, but it’s worth it. The harness supports and stabilizes your shoulder girdle by lifting the fronts of the shoulders up and drawing the bottom tips of the shoulder blades down.

Start in Tadasana and make a large loop in a 10-foot-long strap. (If you don’t have one, you’ll need to hook two straps together to create a big round loop.) Hold the loop behind you and put your arms through it, as though you’re putting on a jacket. Make sure the strap buckle is at the bottom of the loop, so you can reach back and adjust the length of the strap easily. The strap will pass over the tops of the shoulders and under the armpits.

Reach back and take hold of the part of the strap that is lying horizontally behind your neck. Grab this top part of the strap with one hand and pull it all the way down toward the floor. As you pull it down, the bottom part of the strap will pass over it and move up your back, creating a harness.

Reach behind you and twist the strap several times to help keep it in place. Now hold the dangling loop and pull down firmly. When the top part of the strap is pulled all the way down, it should be about hip level. The strap should roll your upper shoulders back and down while pressing your lower shoulder blades into your back. Don’t arch your lower back. Keep your legs and pelvis in Tadasana.

Stay here with your hand pulling down on the strap or, to go a step further, take a dowel or a broom and thread it horizontally through the bottom of the strap. Press your hands down onto the broom. Stay for at least 10 breaths.

Setu Bandha Sarvangasana (Bridge Pose)

According to Iyengar-Certified teacher Roger Cole, when you clasp your hands behind your back in Bridge Pose, you stretch the muscles on the fronts of the arm bones, which makes it more difficult to lift your chest. For this version of Bridge Pose, you’ll use a strap around the ankles to help counteract this.

Lie on your back with your feet flat on the floor and hip-width apart. Your heels should be about six inches away from your buttocks. Place a strap around the front of your ankles and take hold of the strap, one end in each hand. Walk your hands down the strap, toward your ankles. Lightly shrug your shoulders toward your head and roll the heads of your arm bones back, rooting them into the floor. Keeping the backs of your shoulders pressed into the floor, pull on the ends of the strap and begin to lift your chest. Then, by pressing down through your legs and feet, lift your hips toward the ceiling. Lengthen your tailbone toward your knees. Keep pulling on the strap to encourage the heads of the arm bones toward the floor as you breathe and lift your chest.

This article originally appeared on the Yoga Journal and it written by Catherine Guthrie