Yoga for Heart Failure

I feel beautiful.  Participant feedback after an 8-week Yoga course for CHF

Almost six million people in the U.S. have congestive heart failure, and its the most common reason for those over the age of 65 to be hospitalized. Often a pattern develops of frequent hospitalizations, a revolving door in and out.

Many factors contribute to worsening function that requires a trip back to the wards. Stress, depression, and a lack of social support are associated with a worse prognosis independent of other medical or physical risk factors. The American Heart Association notes that stress reduction is one of the most important recommendations for people suffering from congestive heart failure.

Lifestyle changes like exercising, managing stress, losing excess weight, and decreasing the amount of dietary salt can drastically improve the ability to function and the quality of life of people with heart failure.

Yoga has been shown in repeated studies to decrease stress and to alleviate depression. It incorporates physical exercise as asanas and employs stress reduction techniques with breath work and meditation, all potentially helpful practices for those with congestive heart failure.

To determine the feasibility of a Yoga practice for typical heart failure patients, an 8-week pilot study was recently undertaken in northern California. The primary objective was to determine if a community-based, racially diverse Yoga program would be feasible in a low-income area where Yoga and other mind-body modalities are not readily available. The secondary objective of the study was to determine the effects of a Yoga practice on weight loss, depression, and quality of life.

Fourteen men and women took a Hatha Yoga course twice a week that lasted for eight weeks. The program was developed by a local nonprofit group in Oakland, the Niroga Institute, which promotes Yoga for individuals with specific needs. It included, among others things, versions of:

  • Trikonasana (standing side bend)
  • Setu Bandha Sarvangasana (bridge)
  • Supta Padangusthasana (reclining big toe)
  • Paschimottonasana (seated forward bend)
  • Nabhiasana (prone boat)
  • Marjariasana (cat)
  • Ardha Matsyendrasana (seated twist)
  • Viparita Karani (doing inversion, or legs-up-the-wall)
  • Savasana (corpse)
  • Pranayama, exhalation twice as long as inhalation
  • Meditation for 5 minutes in any comfortable position
  • Mindfulness practice for impulse control, enhanced self-awareness, development of fearlessness, desirelessness, detachment, and dispassion


In addition to the group classes, many of the participants practiced individually at home with or without a DVD provided by the Niroga Institute.

Thirteen of the 14 subjects completed the 8-week course with most of them attending at least 75% of the classes. One person joined the group for less than half the time. Given the severity of illness of the group, those are pretty good study retention numbers.

At the end, these 13 people with congestive heart failure felt better overall with their quality of life (as measured by a standardized test) improved. The effect did not reach statistical significance (p = .08), possibly because of such a small sample size. Their depression lessened (as measured by a standardized test) with the number of participants reporting moderate to severe levels decreasing from eight to four, a significant result. There was also a trend in weight reduction. The average loss was 3.5 pounds over eight weeks.

Unfortunately, this research employed no control group and relied upon self reporting for many of the indices. Its a small positive step though, in validating Yogas therapeutic potential, and it corroborates another similarly designed trial of 15 patients with CHF in which quality of life was significantly improved and an improvement of balance, endurance and strength was noted.

I believe that there is little room for doubt about the benefits of a multi-faceted Yoga lifestyle for people with heart failure. Keep in mind as well that the best way to prevent heart failure is to control risk factors and conditions that cause it coronary artery disease, high blood pressure, high cholesterol, diabetes and obesity. Yogas holistic attention to nutrition, exercise, stress reduction, and mindfulness help us to do just that.


  1. Ai Kubo, Yun-Yi Hung, and Jeffrey Ritterman. Yoga for Heart Failure Patients: A Feasibility Pilot Study with a Multiethnic Population. International Journal of Yoga Therapy. 2011; 21:77-83.
  2. Howie-Esquivel J, Lee J, Collier G, Mehling W, Fleischmann K. Yoga in heart failure patients: a pilot study. Journal of Cardiac Failure. 2010;16:742-9.

Yoga for Arthritis

A recent message:

Is it wise to work an arthritic hip with yoga? I have the beginnings of arthritis in my hip.

This is a common concern that maybe we should rest arthritic joints to avoid more wear and tear. From a mechanics perspective, it makes sense. Using a mechanical part too much decreases its life span.

But joints arent inanimate. Theyre part of us, of our living structure. Just like bones and muscles, joints are dynamic structures that need use and attention to keep working optimally. One of the best things we can do is to exercise a troubled joint. Taking it through a full range of motion increases lubrication with synovial fluid. The fluid is full of nourishment, and it feeds the joint for healing. As it washes through, it also cleanses and removes toxic waste products of metabolism and inflammatory mediators.

Exercising the joint through a full range of motion is important, but just as essential is that it doesnt bear more load than it was designed to handle. Even just five to ten pounds of extra weight puts a significant burden on a joint, and shedding those few pounds is absolutely the best thing that can be done to prevent further degradation.

Improving the strength of surrounding muscles with weight training helps. So does increasing the amount of omega-3 fatty acids in the diet, preferably through vegetarian sources like flax seed, chia seeds, and walnuts. Low vitamin K levels have been linked with the progression of osteoarthritis. Eat lots of leafy greens, too.

Persistent organic pollutant, or POPSs, are those nasty synthetic chemicals that have become stuck in our environment, unable to be degraded well either by the elements or by animals. They bio-accumulate through the food chain. Ninety percent of what gets into our bodies comes from meat and dairy, and once ingested they tend to stay in our bodies for decades. Although POPs are generally considered harmless in the concentrations found in humans, there is increasing concern in the scientific community that they may be contributing to our obesity epidemic. There is some possible correlation with arthritis as well. Thats another good reason to follow traditional Yoga advice and avoid animal flesh in the diet. If you like dairy, consider limiting the quantity and choosing organic products in small amounts.


  1. Roush JK, Dodd CE, Fritsch DA, Allen TA, Jewell DE, Schoenherr WD, Richardson DC,Leventhal PS, Hahn KA. Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs. J Am Vet Med Assoc. 2010 Jan 1;236(1):59-66.
  2. Oka H, Akune T, Muraki S, En-yo Y, Yoshida M, Saika A, Sasaki S, Nakamura K, Kawaguchi H, Yoshimura N. Association of low dietary vitamin K intake with radiographic knee osteoarthritis in the Japanese elderly population: dietary survey in a population-based cohort of the ROAD study. J Orthop Sci. 2009 Nov;14(6):687-92. Epub 2009 Dec 8.
  3. Lee DH, Steffes M, Jacobs DR. Positive associations of serum concentration of polychlorinated biphenyls or organochlorine pesticides with self-reported arthritis, especially rheumatoid type, in women. Environ Health Perspect. 2007 Jun;115(6):883-8. Epub 2007 Feb 20.
  4. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011 Jan;14(1):4-9. Epub 2010 Sep 17. Review.
  5. Chyu MC, von Bergen V, Brismée JM, Zhang Y, Yeh JK, Shen CL. Complementary and alternative exercises for management of osteoarthritis. Arthritis. 2011;2011:364319. Epub 2011 Jul 25.
  6. Anandacoomarasamy A, Fransen M, March L. Obesity and the musculoskeletal system. Curr Opin Rheumatol. 2009 Jan;21(1):71-7. Review.

Suryanamaskar and Sacroiliac Pain

A question from a reader:

There is a condition called sacroiliitis which I am told is common among women who have delivered babies.

I was enjoying my suryanamaskaar after such a long time and now it has been suspended on advice. I am not sure that is entirely correct.

Please tell me, can yoga stretches be detrimental now?

Sacroiliitis is an inflammation of the sacroiliac joint (SIJ) located just below the waist on each side of the lower back where you can find a small dimple. Its where the sacrum of the spine joins and interacts with the big pelvic bones. Unlike other joints which are flat and horizontal, the SIJ is almost vertical. All the weight of the body, all our twisting movements and other actions, must be supported by these strange vertical joints.

Because of their odd orientation and big job, the SIJs need powerful ligaments to hold them in proper position. During pregnancy ligaments soften, particularly those in the pelvis, to aid in childbirth. That can loosen the joint on one side or both and cause movement which leads to inflammation and pain.

The SIJs also contain numerous ridges and depressions, indicating their function for stability more than motion. Motion does occur, however, and because of the ridges partial dislocations and even locked positions can occur.

Many muscles interact with these ligaments and the SIJs, including the piriformis, biceps femoris, gluteus maximus and minimus, erector spinae, latissimus dorsi, thoracolumbar fascia, and iliacus. Any of these muscles can be involved with a painful SIJ.

In other words, the SIJs are complicated structures. Diagnosis of dysfunction is complicated, too, and tests are often inaccurate. Depending on the source of pain or the type of SIJ trouble, recommendations of what to do and what not to do vary. Sometimes instructions from various experts seem to contradict each other.

The best advice is to see a qualified physical therapist near you. They will evaluate for subtle differences in the length of the legs (it can change over time) which can be causing trouble. They will look for dislocated or locked joints, tight muscles, weakened muscles, scoliosis, and loose joints from softened and stretched ligaments. Knowing exactly what the problem is will help you to design an appropriate exercise regimen which can and should include Yoga – with proper attention to correct poses.

Although it depends on the particular pathology, a few things tend to increase pain in the SIJs. Anything that increases pain should be avoided as much as possible for at least three weeks to give the joint a chance to heal on its own.

  1. Hyper-extending the leg.
  2. Twisting or rotary motions.
  3. Forward bends, especially with the feet together.
  4. Standing with poor posture.
  5. Repetitive rising from a sitting to a standing position.
  6. Climbing stairs.
  7. Running.

Since suryanamaskar involves forward bends and leg extensions, their performance may aggravate SIJ inflammation and pain. Its reasonable advice to hold off on their practice for two to three weeks to see if the pain goes away. In addition, avoid any asanas that extend a leg out behind, bend the body forward, or twist the torso.

When you resume suryanamaskar, be sure to stand in the opening position with the feet hip-width apart rather than close together as is taught in many Yoga styles. Keep the core engaged with the belly button pulled in to the spine and the back and neck straight. Work into the forward bend taking care not to overstretch the back of the pelvis.

Basically, as with any musculoskeletal inflammation and pain, the best advice is to give the structure a break and let it heal. If it’s continually aggravated by the demands you place upon it, the energy can’t be used for repair.

Since the SIJ is a complicated structure with many adjacent potentially implicated ligaments and muscles, it’s important to determine what elicits pain in each individual. If you find something is aggravating, stop it for three weeks. Then go delicately when you resume.

There are many stretches in Yoga. Finding the right ones for you during different phases or your life and health is the key to a proper and beneficial practice.

Any physical therapists or Yoga therapists out there have anything to add or to disagree about? Any teachers or students have practical suggestions of what’s worked for them? This one isn’t easy, and I’d love to hear from you.

What’s the Right Amount of Salt to Use With Neti?

Salt is added to the irrigation water to make its passage more comfortable.  Our bodies are made of salt water at a concentration generally agreed to be approximately 0.9 percent, or 9 grams of NaCl (common table salt) per liter. Matching that physiological, or normal, concentration makes the solution more comfortable than either plain water or water with a greater amount of salt.  A “physiological” solution is made by placing ½ teaspoon of table salt into 250 ml (or approximately 1 measuring cup) of water.  In scientific jargon, this concentration of salt water is also called “isotonic saline.”

Adding salt may do more than just provide comfort.  A research protocol using fresh water without any NaCl for their placebo had to be stopped when several of the control subjects developed middle ear infections.

Isotonic saline works to clear mucus and relieve sinus congestion and runny noses.  It’s been shown to remove inflammation inducing chemicals like histamine and leukotrienes that the body secretes with allergy. Mucociliary clearance rate, the measure of the speed of removal of mucus, was noted to be increased in allergy patients using 4 ml of isotonic saline twice daily to flush their nasal cavities.

Hypertonic saline, defined as solutions with more than 9 grams per liter of salt, also works. In some studies, a higher salt concentration works better than an isotonic one.  Shoseyov and his colleagues used 3.5 percent NaCl, similar to sea water, and achieved better symptom relief in children than when they used a physiological concentration.

While isotonic solutions are thought to work primarily by their mechanical cleaning effect, hypertonic solutions may additionally decrease swelling.  Extracellular fluid in the nasal mucosa would theoretically be drawn out towards the area of higher salt concentration by osmosis.  There’s conflicting data showing that hypertonic saline may also increase the frequency at which cilia beat, thereby clearing mucus out of the nasal and sinus passageways more rapidly.

Hypertonic solutions might have a downside.  Greiff and his colleagues looked at pieces of nasal mucosa in petri dishes and found that increasing concentrations of saline caused the tissue to secrete more mucus and to react more severely to histamine and another stimulating chemical.  As this study was done in dissected tissue and not live people, the results should be interpreted with caution.

Investigators in another published report did look at the effects of hypertonic solutions in people.  They found that increasing concentrations of saline induced dose-dependent increases in the sensations of pain, blockage, and drippy nose.

In hospitals, hypertonic saline is often used to induce sputum production from the lungs in order to test it for specific bacteria when patients have pneumonia.  It has precipitated asthma attacks in some asthmatics and in those with hyper-reactive airways. Adults and children with asthma need to be careful to avoid aspirating hypertonic saline nasal irrigation fluid into their lungs.

The bottom line is that physiological saline has been found to work, and it’s the least likely salt concentration to cause problems.  If you’re comfortable using a slightly higher concentration of salt, it may give a better response.  The higher the concentration goes beyond what is natural to the body, the more likely there are to be side effects.  Don’t go any higher than 3.5 percent, the concentration of sea water.  Dr. Rabago, a family physician who studies neti, prefers 2 percent. That would be roughly equivalent to 1 teaspoon per 250 ml or 1 measuring cup of water.  He advises patients to adjust the concentrations of salt to their own personal preferences.

How to Quit Smoking: Comprehensive Strategy

Planning in advance and setting a quit date

Here are three things that you need to do before you even try to quit smoking. I would strongly recommend that you do all 3 of these things if you are serious about this. I promise this will work for you if you follow it as planned, because it contains excellent preventative measures for nearly every pitfall that a smoker can run into when they try to quit. Believe me I have done this enough times, and when I finally pulled it off and quit smoking for good 4 years ago, I knew that I had uncovered a truly wicked formula for kicking the habit.

So here are the 3 things:

1) Pick a quit date. Most will need to make this at least 2 to 3 months in advance, due to the other 2 requirements.

2) Start exercising every single day, if you do not already do so. This must be a minimum of 30 minutes per day. No excuses! Do it.

3) Take time off work for the quit. Preferably 2 weeks. Dont say you cant. Just move the quit date further ahead and save more money. No more excuses. Do it if you want to quit.

So these are your preparation steps. You need to start exercising every single day, without fail. This cannot be missed. If you do this it will make it so much easier to stay off of cigarettes forever. You need two weeks off work in order to really make this work right and you also need lots of extra money. Save it up. Dont say you cant. That just means you want to keep smoking and die of lung cancer. Make a decision that you are going to do this for yourself, it will be awesome and you are going to have fun doing it.

Getting through withdrawal with a sledgehammer

OK so here is what you need to do. You are rapidly approaching your quit date and you have some time off work too. On your quit date, smoke your last cigarette and then throw everything away. Throw out your lighters, ashtrays, have a cleaning party. Try to get rid of all the negative, lingering effects of your smoking habit. If you try to hang on to any cigarettes at this point then just forget it and go back to smoking, you are not ready yet. You MUST throw out any remaining cigarettes. Soak them in water and throw them in the garbage. If you dont do this then you have already failed.

Go to the store and buy 3 big containers of cranberry juice. Also buy some chewing gum, chewing toothpicks, and bic pens that have clickers on the ends of them. You might use the gum, the chewing toothpicks, and possibly candy in order to keep your mouth busy over the next week. You might also use the pens and the clickers on the end of them to keep your hand busy while you are walking around in nicotine withdrawal. It helps a little.

So here is how you dominate your nicotine withdrawal in a big way:

Smoke your last cigarette and start drinking the cranberry juice. Do not go to sleep for 36 hours straight.

Review that last sentence again as it is extremely important: Do not go to sleep for the next 36 hours. You are going to stay awake on purpose in order to cut your withdrawal time in half. This actually works, I have done it. It worked perfectly.

Stay up for 36 hours and keep drinking the cranberry juice while you do this. You dont want to over do it of course, but you want to be drinking the stuff steadily over the next 36 hours. Keep sipping it. You will get sick of it. Keep sipping it anyway. It will obviously make you urinate quite a bit. Drink as much as you comfortably can. Keep it reasonable. But keep sipping it.

What you are doing is flushing the nicotine out of your system much faster than usual. This is going to make your withdrawal much faster and much more intense and much worse. However, you are going to sleep through it! That is the beauty of this system. Stay up for the full 36 hours and keep slamming the juice, then crash out at the 36 hour mark and go to sleep.

When you wake up, your withdrawal will be very close to being over. Completely.

This is a beautiful system and if you do it perfectly then you will only be in withdrawal for about 24 hours instead of for 7 days straight. It will be a little bit crazy when you stay up for the 36 hours and slam your juice, but you can have a party and celebrate your new smoke free life while doing this. Or you can just hang out or whatever. It doesnt matter. Make it through this portion of it and you are home free, at least as far as acute withdrawal is concerned.

Massive distraction for the win

The next part of your quit smoking strategy is to make it through day 4 through 14. You already made it past the acute withdrawal stage in days 1 through 3 by sleeping through most of it. Now you are almost out of the woods but you are still on shaky ground. You need a distraction to get you through to the 2 week mark.

This is why I recommend a vacation from work. If you are stuck back at work and you are comfortable smoking there, then that will be a huge trigger. Not a good distraction. What you need is a family vacation. If your family all smokes then take a personal vacation. Whatever. It doesnt matter. But I would plan to go somewhere as both a celebration of your quitting smoking and as a distraction to help you to stay quit in the early stages.

You want a vacation planned where you actually do stuff. Sitting around on the beach all day is probably not the best thing for you. Think more along the lines of amusement park, running around with kids all day until youre exhausted. Yes this might have some stress associated with it, but it is better than sitting idle and ending up relapsing because of it.

Take off work and plan a vacation. The trip will help you to transition into a life of non smoking. And it doubles as a nice reward strategy.

If you say you cant afford it, then you are not planning properly. Save your money and push your quit date further ahead. Are you going to do this or not? No excuses.

How Does Neti Work

Nasal irrigation with neti works by:

  • · Mechanically flushing out bacteria, viruses, dust, and allergens
  • · Thinning remaining mucus so that sinuses and ostia don’t clog
  • · Decreasing swelling of the nasal mucosa
  • · Removing histamine, leukotrienes, and other inflammatory substances
  • · Increasing frequency that cilia beat to remove mucus, crusts and debris

Is There Clinical Proof That Neti Works?

Yes, there’s scientific evidence that flushing with salt water works to decrease the symptoms of rhinosinusitis, or inflammation of the mucosa of the nasal cavity and sinuses that occurs in response to viruses, allergens, bacteria and other irritants.

A study published in the Archives of Otolaryngology Head and Neck Surgery in 1997 asked participants a survey of questions known as the SNOT-20.  They were asked about 20 symptoms such as the need to blow the nose, sneezing, postnasal drainage, cough, runny nose, congestion, trouble sleeping, and more.  Compared to controls that were simply spraying saline into their noses, participants flushing with normal saline (0.9%) using Sinus Rinse irrigations had fewer symptoms, and they experienced those symptoms less often.  They achieved a clinically significant improvement in their quality of life as measured by the SNOT-20 while the spray group did not.

In 2002, Rabago and his group in Wisconsin irrigated the noses of study subjects with 150 ml of 2% buffered saline (1tsp heaping of canning salt, one-half teaspoon of baking soda, and 1 pint of fresh tap water) daily into each nostril for six months.  They found a statistically significant reduction of symptom severity and an improved quality of life.  Use of antibiotics and medical nasal sprays decreased.

Heatley et al also noted that patients reduced their use of medicines significantly due to improvement of symptoms with this natural method of healing.

A study published in Laryngoscope used store-bought dental Water-Pik devices with Grossan nasal adapters (Hydromed or Kenwood Therapeutics) to irrigate both nostrils of subjects with 250 ml of lukewarm tap water with a half teaspoon of table salt twice a day.  They reported improved symptoms of congestion, postnasal drainage, allergies and discharge in 23 out of 30 participants after six weeks of use.  92% of the study participants completed the six week program, signifying its practical ease of use.

A 2009 study looked at the common cold in children.  On average, kids get 6-8 per year, and the US Food and Drug Administration recently changed the label on all over-the-counter cold medicines to prohibit their use in kids younger than 6 years of age.  In this report, 69 children aged 3-12 years first saw a film on neti and witnessed a facilitator perform it.  They then demonstrated proficiency using disposable syringes filled with 15-20 ml of normal saline (0.9%) per nostril, and were instructed to perform the action 1-3 times per day. At the end of the study period, the children showed an overall improvement in nasal air flow, decreased symptoms indicating improved quality of life, and an improvement of pathology noted on sinus X-rays.

A small randomized controlled trial in children with lab confirmed pollen triggered symptoms found that saline irrigation in addition to antihistamine pills significantly reduced allergy symptoms and the amount of medicine taken.  In comparison, when only antihistamine treatment without nasal irrigation was used, kids were noted to obtain less symptom relief and required more medicine to be comfortable.

Adults with hay fever, have also reported improvement of allergy symptoms when using saline nasal irrigation in clinical trials.

Pregnancy inhibits many women from using cold and allergy medicine for symptom relief.  A recent study asked pregnant women with seasonal allergies to irrigate their sinuses with saline containing a higher than usual concentration of salt.  They irrigated 3 times daily for 6-weeks as opposed to a control group who used no local therapy.  Those irrigating noted a statistically significant improvement in symptoms from 2-weeks on throughout the remainder of the trial.  Rhinomanometry, a measure of nasal airway resistance, also improved, an objective measurement of decreased congestion and ease of breathing through the nose.

Woodworkers with chronic symptoms from wood dust demonstrated significantly improved mucociliary clearance and nasal air flow on expiration after a program of nasal saline irrigation.

Neti has also been show to be an effective method for preventing viral infections of the nasal cavity and sinuses.  A randomized, controlled study of 60 adults found that those performing daily nasal irrigations had fewer episodes.  When they did get infected, their symptoms lasted fewer days.

There’s also a preventative effect in kids.  In a randomized, controlled study of 390 children, those irrigating their sinuses with saline had fewer episodes of sinus congestion and runny noses.  Those using neti on a preventative basis were less likely to end up being treated with medication.

There are many more scientific studies showing positive and genuine results with neti, too many to write about them all.