Introduction | Adaptive Yoga in Occupational Therapy

This post introduces yoga, similar concepts of both occupational therapy and yoga, and provides a rationale for utilizing yoga as an adjunct intervention for neurological conditions in occupational therapy.

This information provided here is for educational purposes only and is not intended to treat, diagnose, or manage any specific illness or disease. It is always advisable to consult with your healthcare provider or doctor prior to beginning any yoga or exercise program. The information detailed below pertains specifically to stroke rehabilitation and its potential integration with yoga practices.

Brief Introduction to Yoga

Yoga is an ancient practice that originated in India and is characterized as a mind-body discipline aimed at developing concentration and awareness.

The word "yoga" is derived from the Sanskrit root "yui," which means "to yoke” or join together (Lawrence et al., 2017, p. 2).

The Eight Limbs of Yoga

Patanjali’s Yoga Sutra outlines the eightfold path, also called the eight limbs of yoga, serves as a roadmap for living a purposeful, ethical, and meaningful life (Lawrence et al., 2017, p. 2) and (Woodyard, 2011).

• The 8 limbs of yoga are the values of yoga.

• Yama (restraint)

• Niyama (observances)

• Asana (posture)

• Pranayama (breath)

• Pratyahara (turning inward)

• Dharana (concentration)

• Dhyana (meditation)

• Samadhi (Oneness with all living things)

• The 3 limbs that are the most used in healthcare include:

• Pranayama (breath)

• Asana (posture)

• Dhyana (meditation)

Adaptive Yoga

Adaptive yoga is a form of yoga that utilizes props and modifications to make it safe and accessible for individuals of all abilities.

• Unlike traditional yoga, which may have fixed poses and sequences, adaptive yoga modifies postures, movements, and breathing techniques to accommodate various physical limitations, cognitive impairments, or other health concerns.

• It aims to empower practitioners to experience the numerous benefits of yoga in a supportive and inclusive environment.

• By adapting poses and using props, individuals can practice yoga without any discomfort or injury, and enjoy the physical and mental benefits of the practice.

Elements of Adapted Yoga include:

• Seated on chair or standing using aids for support.

• Avoid supine, semi-supine, or prone asana.

• Hold static asana (isometric postures) for a shorter length of time. 

• The physical environment is adapted to suit people with a sensory impairment (e.g. lighting levels being higher, color of equipment being in contrast to that of the walls and floor, and no music played during instruction. 

• Pace and overall structure allows for greater time for recovery. 

• Instructions are short, single-point sections with time allowed for information processing to facilitate understanding in individuals with cognitive impairments. 

• Longer warm-up and overall slower pace. 

• Breathing practices avoid retention (contraindicated for individuals with hypertension).

• Dharana (concentration and meditation) specifically focus on balance and coordination (Tew et al., 2017).

The essential elements of adaptive yoga include:

• Intention

• Breath

• Alignment

Adaptive Yoga as a Therapeutic Intervention

• In adaptive yoga, therapists tailor poses, sequences, and practices to accommodate the unique needs and abilities of each student.

• This may involve the use of props such as blocks, straps, chairs, or bolsters to provide support, stability, or assistance in achieving poses.

• Research indicates that adaptive yoga, an integrative treatment modality, holds promise for individuals recovering from stroke.

• Adaptive yoga has been shown to have clinical benefits in rehabilitation, such as:

• Improving hip and knee flexion

• Rib and spine mobility

• Functional applications like dressing, transfers, balance, and breathing (Yang & Fahey, 2021).

Similar Concepts of Occupational Therapy and Adaptive Yoga

Stroke occupational therapy rehabilitation and adaptive yoga share common elements in their approach to restoring mobility and function, mainly through techniques such as neuromuscular reeducation (e.g., proprioception, coordination, balance, and weight bearing), range of motion (e.g., passive and active), increasing fine motor skills, use of adaptive equipment (e.g., Long-Handled Reacher and yoga block), stress management training, cognition and sensory integration, and functional mobility.

Neuromuscular Reeducation

Weight-bearing exercises, which are crucial in stroke rehabilitation, play a significant role in neuromuscular reeducation. This term refers to the process of retraining the muscles and nerves to work together following a stroke. In stroke rehabilitation, weight-bearing helps to improve proprioception, reduce neuron excitability, and decrease spasticity. Weight-bearing involves placing some of the body's weight through the affected extremity to provide a low load on the joint.

Similarly, adaptive yoga includes poses and sequences that encourage weight bearing through seated, standing, quadruped, and bridge poses. Similarly, weight shifting is a traditional element in stroke rehabilitation. Weight shifting is a fundamental movement where the body's weight moves from one position to another. Approximately 35% of patients with chronic stroke experience impaired weight-shifting ability (Liao et al., 2018).

An impaired ability to shift weight and maintain balance increases the individual's risk of falls and reduces their independence in activities of daily living. Another neuromuscular reeducation technique is bimanual movement coordination. Bimanual movement coordination is an evidence-based stroke rehabilitation intervention involving using both extremities simultaneously. Incorporating contralateral movements can activate both brain hemispheres and focus on repetition, which increases neural connections and the brain's neuroplasticity for new motor movements (Yang & Fahey, 2021, p. 32).

Range of Motion

Research indicates that including yoga in stroke rehabilitation can speed up recovery by improving range of motion, increasing awareness, and reducing pain (Yang & Fahey, 2021). Range of motion (ROM) in the upper and lower extremities is crucial for performing daily activities.

It refers to the extent to which a joint or body part can be moved. Different daily activities require specific ranges of motion. For instance, bringing a fork to one's mouth requires about 70-100 degrees of elbow horizontal adduction and 45-60 degrees of elbow abduction.

In stroke rehabilitation, passive range of motion exercise involves the therapist moving the patient's limbs through a full range of motion to prevent stiffness and contractures. Similarly, in adaptive yoga, instructors may provide gentle assistance and manual support to facilitate passive stretching and movement in hemiparetic limbs. Active range of motion exercises are important in stroke rehabilitation and adaptive yoga to enhance strength, flexibility, and coordination.

In stroke rehabilitation, patients are encouraged to use their muscles to perform movements independently. Similarly, adaptive yoga incorporates active movements tailored to individual abilities, promoting muscle engagement and neuromuscular reeducation.

Fine Motor Skills

Mudras are hand gestures that occupational therapists use in stroke rehabilitation. The word "mudra" means "seal" or "closure" in Sanskrit (Schmid & Van Puymbroeck, p. 187, 2019). Mudras help direct the flow of energy with the hands and are associated with benefits such as increased energy and balance throughout the body (Schmid & Van Puymbroeck, p. 187, 2019). They activate specific brain areas and are usually used in conjunction with pranayama (Schmid & Van Puymbroeck, p. 187, 2019).

Incorporating mudras into stroke rehabilitation requires some considerations due to the fine motor skills and hemiparesis often experienced by stroke patients. Although many mudras involve both hands, individuals with stroke-related motor deficits can be instructed to perform the mudra with one hand and visualize the other hand performing the mudra (Schmid & Van Puymbroeck, p. 187, 2019).

Visualizing the mudra allows patients to fully engage in the yoga practice and may increase their participation. Mudras can also serve as beneficial homework for patients to work on outside of therapy (Schmid & Van Puymbroeck, p. 187, 2019). In occupational therapy, mudras are similar to assessments for evaluating coordination, finger opposition, and improved fine motor dexterity and strength, with the goal of carrying over these improvements to meaningful daily activities.

Adaptive Equipment

Occupational therapy adaptive equipment and adaptive yoga props promote independence in activities but have different purposes. Adaptive equipment utilized in occupational therapy for dressing and grooming includes a long-handled reacher, long-handled shoehorn, and sock aids.

These tools enable patients with stroke to increase their independence in dressing and grooming. Additionally, adaptive equipment such as shower chairs, tub benches, and long-handled sponges increase an individual's independence in bathing. Similarly, props used in adaptive yoga include yoga blocks, bolsters, straps, sandbags, and pillows. These props increase an individual's ability to participate in the postures and movements.

In adaptive yoga, props are commonly utilized to enhance participation; however, it is essential to note that alternative props are available in occupational therapy rehabilitation facilities, showcasing their versatility. For instance, wooden therapy blocks 4 inches in height, foam rollers, or therapy pillows can be used instead of yoga blocks. Instead of yoga straps, therabands can be used, and towels or hospital blankets can replace yoga blankets. Similarly, therapy wedges, thick mats, foam rollers, and large pillows can be used instead of yoga bolsters. By utilizing such alternatives, individuals can continue to benefit from adaptive yoga, even if traditional yoga props are unavailable.

Stress Management Training

The use of relaxation techniques in occupational therapy provides patients with numerous health benefits. These benefits include lowering blood pressure, slowing heart rate, and reducing chronic pain (Kim & Lee, 2015). Some relaxation techniques used in occupational therapy are meditation, breathing techniques, progressive muscle relaxation, and mental imagery.

Mental imagery is particularly effective in stroke rehabilitation, as it helps induce motor sensations through internal thoughts, activating brain areas and muscles similarly to motor control (Kim & Lee, 2015). Yoga Nidra, a method for relaxation in yoga, aims to enhance consciousness and trigger the parasympathetic nervous system. It is a type of mental imagery used in adaptive yoga to promote relaxation and increase body awareness through specific techniques that focus on each body part, encouraging neuroplasticity (Pandi-Perumal et al., 2022).

Functional Mobility

In stroke rehabilitation through occupational therapy, focusing on transfers and functional mobility is crucial for helping patients participate in meaningful activities. An effective approach involves incorporating yoga, particularly sequences like Sun Salutations.

These sequences involve coordinated movements and motor control, which can potentially enhance individuals' ability to perform transfers and improve functional mobility. Sun Salutations consist of a series of physical postures (asanas) designed to promote coordination, balance, and enhanced motor control. Integrating sun salutations and asanas into occupational therapy treatment may play a vital role in stroke rehabilitation.

Occupational Therapy and Integrative Health

According to AOTA, an occupational therapy practitioner can use integrative health approaches as a preparatory method or purposeful activity when providing occupational therapy services (Graham & Plummer, 2018). Integrative approaches and modalities approved by AOTA include yoga and meditation, guided imagery, massage, myofascial release, and behavioral relaxation training (Graham & Plummer, 2018).

In 2011, AOTA's Commission on Practice developed the Complementary and Alternative Medicine (CAM) position paper, which endorses the use of Complementary and Alternative Medicine as part of the occupational therapy plan of care (Graham, 2018).

The literature suggests that complementary and alternative medicine can be used either as preparation for treatment or as a therapeutic activity, depending on the treatment plan (Graham, 2018). Preparatory methods and techniques in occupational therapy prepare the client for their treatment session. They may include a range of motion, manual techniques, physical agent modalities (PAMs), therapeutic exercises, orthotics, or massage (Graham & Plummer, 2018). 

The National Center for Complementary and Integrative Health (NCCIH) defines preparatory methods as "a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine" (Mortada, 2024, p. 1). The use of preparatory methods and techniques in occupational therapy are useful to enhance a patient’s treatment session and help aid in occupational performance.

According to the American Occupational Therapy Association, integrative health approaches may be used as occupational therapy interventions to enable or enhance participation in meaningful activities (The American Journal of Occupational Therapy, 2023). Some integrative health approaches include Yoga, Tai Chi, and Mindfulness. Furthermore, integrative health occupational therapy (IHOT) incorporates occupation-based and client-centered occupational therapy with complementary health approaches (The American Journal of Occupational Therapy, 2023).

Integrative treatment approaches in occupational therapy stroke rehabilitation have effectively enhanced patients' physical, mental, and functional outcomes. However, existing occupational therapy rehabilitation programs predominantly focus on improving physical function while neglecting the functional and psychological aspects of stroke. Integrative health approaches can address the individual's holistic needs, emphasizing the importance of treating the person as a whole. Despite their potential to change a patient's ability to perform skilled tasks, occupational therapy practitioners do not commonly utilize such approaches.

According to the American Occupational Therapy Association (2023), outcome assessments in Integrative Health Occupational Therapy (IHOT) are chosen based on the patient's stated occupational performance needs or desires, values and belief systems, and the theoretical framework used to guide the occupational therapy process. This patient-centered approach is crucial, as it ensures that the therapy aligns with the individual's unique needs and circumstances. Adaptive yoga, a versatile tool, may not be suitable for all individuals, and the patient's needs must be at the forefront when utilizing integrative health approaches in occupational therapy intervention. This emphasis on patient-centered care fosters a deeper connection between the occupational therapist and the patient, enhancing the effectiveness of the therapy. 

Yoga is highly versatile, making it a valuable tool for stroke rehabilitation. However, when working with patients who have a history of stroke, there are numerous guidelines to keep in mind when employing adaptive yoga techniques. When utilizing yoga for stroke rehabilitation, it is up to the occupational therapist to determine the type of treatment (one-to-one or group yoga) necessary to enhance function in each stage of stroke recovery (Schmid & Van Puymbroeck, 2019).

Additionally, understanding how to adapt the pose for the patient is crucial to facilitating growth and recovery after a stroke (Schmid & Van Puymbroeck, 2019). When standing, patients with balance and stability issues can benefit from wearing an ankle or foot brace (Yang & Fahey, 2021). In addition, postural deficits are a crucial factor to consider. Patients typically display a forward flexed posture following a stroke and may favor their hemiparetic side. Therefore, it is essential to target the hip extensors and paraspinal muscles and obliques bilaterally to address the postural deficits frequently seen in stroke patients (Yang & Fahey, 2021). Strengthening all muscle groups is helpful to promote recovery after a stroke. However, emphasis should be placed on the antigravity muscles (hip extensors, knee extensors, and plantar flexors) (Yang & Fahey, 2021). As balance deficits are an ongoing issue after a stroke, it is crucial to challenge balance progressively to develop balance and strength while maintaining safety (Yang & Fahey, 2021).

Although there is a natural overlap between stroke rehabilitation and adaptive yoga, there is a lack of research and knowledge about the role of occupational therapy utilizing adaptive yoga for stroke rehabilitation. Occupational therapy and adaptive yoga are holistic approaches that focus on the whole person and promote client-centered intervention. Research suggests elements of yoga can be used within occupational therapy as preparatory methods (e.g., stress reduction tasks), activities (e.g., yoga poses for standing balance), and occupations (e.g., meditation for pain management) (Graham & Plummer, 2018). According to Schmid & Van Puymbroeck (2019), yoga is one of the few occupational therapy interventions that targets multiple body systems affected by stroke and treats the entire body.

Many people experience strokes and other neurological issues, creating a demand for new occupational therapy methods. Adaptive yoga has become a valuable supplement to standard stroke rehabilitation techniques. Combining different treatment methods in occupational therapy can effectively enhance physical, mental, and functional results for stroke patients. Incorporating yoga into therapy may lead to better patient outcomes.

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