Dr. Derya’s Blog

Have you ever wondered what the PRI approach (what I primarily practice) and a meditative practice have in common?

Probably not, but I sure have!

Some Background on Meditation

Some of you know my history of meditation- I spent the year of 2012 staying at different meditation centers all over the country learning the practice of Vipassana, or “Insight” meditation. We meditated for 10 hours a day, for 10 days, in silence. It was intense!

Vipassana is not a religious practice, in fact there is no “belief” involved at all, which I appreciated. Instead, you practice observing the reality as it is- starting with the sensations in your body.

By simply observing your sensations, you becomes aware that everything is constantly changing, constantly in flux, constantly in flow. Once you can appreciate that in your own body, you begin to see it all around you. The seasons change from winter to spring, the sun rises and sets, we get sick and feel better, clothes get dirty and get washed, etc. With this understanding, we can let go of attachment and be present and in the moment.

So What Does All This Have To Do with Physical Therapy, specifically a PRI approach?

In particular, there are three things that I find are eerily similar in the PRI approach to movement and meditation. These aspects are consistently challenging for patients, but once appreciated they have profoundly better results.

Forgetting is the Practice

In meditation, many people think that they must clear their mind of thoughts and be aware of the breath the whole time. Thusly, many people get frustrated and give up, thinking, “I’ll never be able to clear my mind!” However, this is not actually the goal of meditation.

In fact, we need to forget about the breath in order to be able to come back to it. When you say, “ah my mind has wandered, let me come back to the breath,” in a kind and gentle way, that is the practice. The forgetting is necessary because you get to come back. And that is meditation.

There are studies on monks who have achieved very deep levels of meditation after decades of meditation. The authors looked at their brainwaves and found that, rather than being continuously concentrated, their minds were forgetting and coming back so quickly and frequently that it was perceived as continuous.

When I am working with patients, I always have them focus on what they sense and their breath. Just like in meditation, you will forget your breath, you will forget your felt sense, especially when I give you several different senses to focus on. It becomes harder, if not impossible, to focus on all of them at the same time. So, you have to shift your attention throughout your body.

This is very intentional.

It is connecting the body and the brain, connecting right and left, top and bottom and front to back. This is why the techniques I give are often called “magic” by my patients because they work so fast. It’s not magic, it’s the power of sense, of integrating brain and body, vs just strengthening or stretching or massaging or dry needling a specific muscle (which rarely works long term because your brain does not think about your body as individual muscles, but rather as patterns of movement and chains of muscle and connective tissue).

A Word on Sense

Perhaps the biggest commonality I see between meditation and PRI is that when practitioners struggle, it is almost always because they are looking for something special.

When we meditate, we aim to feel our body, exactly as it is. That may be as simple as feeling your butt sitting in the chair or on the floor. THAT IS A SENSATION! We are always looking for something special, for the clouds to part and rain down colors into our chakras or whatever. Trust me that’s not what happens (at least for most people, haha!)

Observing the reality, as it is, is extremely powerful and profound over time…and also kinda boring in the moment.

Similarly, when practicing a PRI technique, I might say, “do you feel your right butt doing something?” The answer I often get is, “no I feel nothing!” But after probing deeper, it turns out they did feel something but it was just light activation, or perhaps even just an awareness of the area. That counts as SOMETHING!

Often with exercises we are looking for a strong sensation of a muscle contraction or stretch, or even pain (which you should never feel during therapeutic exercise, in my opinion). If the sensation is not strong, or just an awareness, we just ignore it. (This is also why the techniques I give out are called techniques and not exercises, they are different).

Don’t do that! The subtleties are how we change our brains, nervous systems, and bodies. And sometimes the sensation is just so simple it seems too easy! For example, I’ll say, “do you feel your left heel?” Often the answer is, “I’m not sure,” or “no.” You’re standing on it. There is floor under your foot. You may not notice it until I point it out, but you do feel it.

The key to success, in meditation or your PRI techniques, is to stop looking for something special, and just be with the reality as it is.

Middle Path

One thing I am always telling my patients is to “try less hard.” When we are tasked to do something, like a PRI technique, there is the tendency to try hard to do it right.

After all, if I try harder, it will be better, right? And if I do it better by trying harder, then I will get better faster, right?

It is counterintuitive, but when we are trying to change a movement pattern we must be in a parasympathetic, relaxed, “rest and digest” state so that the body can accept the new information from the brain.

If we are keyed up in a “fight or flight” sympathetic state, the brain and body can no longer accept new information because you have shifted into survival mode. When we are “trying hard” we are in a more sympathetic state.

This is actually a good thing that our body does- when we need to achieve a challenging task, trying hard kicks on the sympathetic system which helps us get the task done. But we are not meant to live in a sympathetic “fight or flight” state. We are meant to be sympathetic for short periods and then go back to our usual parasympathetic, rest and digest state.

Unfortunately, nowadays many of us live in a sympathetic state due to all the stressors that were not present for primal humans (traffic, work, emails, screens, the news, oh my!)

So, by “trying less hard” you are practicing the middle path, which is what the buddha taught. This means you are not over-efforting, but you are still putting in some effort so you are not under-efforting either. It is somewhere in the middle, hence, middle path.

When the buddha was on his way to enlightenment, he tried some very severe ascetic practices which included starving himself. He found that these extreme practices did not yield results, and that a more moderate approach was far more effective. Any extreme will create stress in the body.

Some stress is good, and sometimes we do need to try harder and push ourselves. But we are not meant to live in that state! When trying to rewire our brains and bodies to be a different way for most of the time, the middle path is the best way to go.

Change

Change is inevitable. If you are working with pain or an injury, and you do nothing, it will still change. Sometimes it will get better, and sometimes it will get worse. But it will certainly change. In location, intensity, duration, or some other factor. Taking action to address your symptoms will also result in change!

Unfortunately, I have seen many patients who have had unnecessary and sometimes quite invasive procedures that, in my opinion, they didn’t need and that didn’t resolve their issue because their pain was coming from a movement pattern, not a specific joint or nerve root. If we can clearly understand the root cause of the problem, with a thorough assessment, we are much more likely to achieve the changes we want vs just any change.

In meditation, we practice observing the reality as it is, and the reality is that everything is changing all the time. When we can observe, objectively, the inevitability of change, we are better able to preserve our equanimity throughout the vicissitudes of life.

Our bodies are similar, in that if we can sense and practice the movements in our bodies that are less accessed by our brain, and place some intention on moving in and out of patterns in a balanced way, then our bodies will also be better able to maintain their fluidity and stability through all the challenges and changes that will inevitably come in our lives.

Have you ever tried to meditate? Did any of this resonate with you? Write me back and let me know your experience!

Kindly,

Dr. Derya

Somehow I managed to find 10 minutes of “me time” in my day to wind down, so I put on a relaxing guided meditation. I settled into a comfortable seat. I was feeling calmer, quieter, more relaxed, until….the teacher’s soothing voice instructs me to “take a nice big breath into your belly, and let your belly drop back as you blow out.” It took a lot for me not to throw my phone across the room in annoyance. Sigh. Another relaxing moment ruined by belly breathing!

You see, instructing “belly breathing” is a little bit of a pet peeve of mine. Because it’s not helpful, and in many cases it is harmful. Unfortunately, most of you have been told to belly breathe at some point in your life, by a well meaning healthcare provider, yoga instructor, meditation teacher, or YouTube video. Sometimes it is taught with a correct understanding of breathing mechanics so that it is actually helpful, but 90% of the time it is not.

So why is everyone so obsessed with belly breathing?

In an attempt to prevent “tension breathing” (shoulders rising to pull air in with your neck muscles) it was decided that the solution to that is “belly breathing.” This concept has become very popular and it’s even what I was taught in physical therapy school! The idea is that while your neck and shoulders stay relaxed, you expand your abdomen/belly on the inhale, and let your belly drop back in towards you on the exhale.

Unfortunately, this cueing is problematic for many, and can cause just as many issues (if not more!) than tension breathing. Neither is good, but let’s not trade something bad for something worse!

A Little Anatomy

To understand how belly breathing can be problematic, we first need to understand the anatomy of breathing.

The Ribcage and Pelvic Floor

The rib cage and pelvis both have diaphragms at their base, the respiratory and pelvic diaphragms (a.k.a. the pelvic floor).

The respiratory diaphragm lowers and flattens slightly as it contracts, creating negative pressure that pulls fresh air in as the chest wall expands.  Yay!

As the diaphragm descends, it creates creates some distension (stretching) in the abdominal cavity and pelvic floor. But more importantly, the ribcage expands in 3 dimensions (yes, in the back too, in fact that should be where most of the expansion occurs) as air flows into the negative pressure created by the descending dome of the diaphragm.

During inhalation, some distension of the abdomen is normal, but it SHOULD NOT BE MORE than your ribcage distension. If you repetitively OVER distend your abdomen, through improper breathing, postural changes, improper training, or intentionally via belly breathing you lose the elastic recoil of the tissues of abdominal muscles and pelvic floor, and therefore you lose the ability to passively push air out with your abdominals, pelvic floor, and diaphragm.

You lose the trampoline-like recoil that allows the respiratory and pelvic diaphragms to effortlessly return to a relaxed, elevated position. Quiet breathing should be effortless, and this is how that is achieved.

Think of a rubber band that gets stretched repeatedly to its limit, until it no longer bounces back like it used to. That’s essentially what happens to your breathing mechanism when you repeatedly belly breathe. Once you lose that recoil, it takes a lot of time and awareness to restore that abdominal and pelvic floor tone.

Some individuals develop belly breathing unintentionally as a way to work around a stiffening rib cage that occurs due to lifestyle and postural changes. In my world, we call this type of unconscious belly breathing pathological.

I.e. belly breathing is a problem, causing lots of other problems, so we need to treat it to allow the individual to oxygenate properly and resolve the back pain, neck tension, and other issues that arise from lack of abdominal tone and recoil. So we treat that by retraining the abdominals as breathing muscles and restoring ribcage expansion. And then you feel better and breathe better!

But why, oh why! would you ever intentionally do that to yourself?!?!

Whew, okay had to get that out. Let’s continue!

A Stuck Diaphragm

The diaphragm likes to maintain a nice dome shape, which is created and supported by the tone of the abdominals and pelvic floor muscles. If you can’t get the diaphragm to ascend into a dome (because of too much distension of the abdominal wall and pelvic floor), the diaphragm remains in a contracted, flat, stuck position. Without this dome shape, the only way to get air in and out is to extend our back and “pull” air in with our neck muscles (just what we were trying to avoid in the first place!) because the diaphragm sure can’t help you now.

The diaphragm is no longer a respiratory muscle and has become a postural muscle, stiff and toned to hold you up rather than supple and mobile to pump air in and out.

The Psoas and the Breath

The diaphragm fibers are intimately connected, and in fact continuous, with the psoas muscles.

The psoas attaches to spine and hips, and when it becomes tense it creates an excessive arch in lumbar spine and tightness in the front of your hips (so if you have been told that you have tight hip flexors, it’s probably because you can’t breathe with your diaphragm. Annd no amount of stretching or massage will fix that until you can get your diaphragm to work properly. But that’s another rabbit hole for another day).

When the diaphragm becomes tense and stuck, so must the psoas, furthering your inability to use your diaphragm as a breathing muscle and forcing both the diaphragm and psoas to act as postural stabilizers.

This results in low back pain, neck pain, and all sorts of other fun issues that arise from, essentially, an inability to breathe!

So What Should You Do?

Instead of breathing into your belly, breathe into your back! Let your abdominals WORK as breathing muscles instead of being functionally inhibited by poofing your belly out for every breath.

The short answer: No more belly poof. Please.

Most of your lung field is in the back of your ribcage, and getting air into your back allows for the ribs in the front to be pulled down by the abdominal muscles, which retrains the abs to be breathing muscles (your abs are breathing muscles first! That is their primary function).

Try these techniques to restore proper breathing, and please please PLEASE be careful with belly breathing, if you must do it at all! In my experience, belly breathing that is just poofing out your belly to inhale and letting it drop has no inherent value, other than it makes you pay attention to your breath, but you can do that in lots of other ways without creating pathology.

The Power of Restorative Yoga

Winter is a time where all of nature slows down, the nights are longer, the days are shorter. Animals hibernate after spending time gathering food to hunker down for the colder season.

Trees shed their leaves to prepare for new growth in the spring. The whole natural world accepts this as part of the cycles of life- the ebb and flow of rising and falling energy through the year.

Except for us humans! Even though everything around us slows down, we still attempt to function at 100 miles per hour. This can be taxing, but it is ESPECIALLY hard on us when our true nature is to soften and quiet during this season. Restorative Yoga is about deep rest and finding time to restore and recharge ourselves.

This practice is what we tend to resist, but what we need more than ever right now. 

How does restorative yoga work?

Unlike the more active forms of yoga, restorative poses focus on supporting your body so that your mind can relax. Your nervous system realizes that it doesn’t have to hold you up anymore- you are being held and supported by what’s around you.

This is extremely relaxing and people often report a sense of deep restfulness after a restorative class that they haven’t felt in months, years, or sometimes ever!

At first it may be hard to lie still, especially if you are someone who is always on the move. However, these are the people I find need this practice the most.

After the first pose or two, they are able to settle and end up getting the most out of it. If you’ve never tried Restorative Yoga, now is the perfect time! And it’s perfect for later in the evening to help you wind down and get ready for deep and restful sleep. 

I hope you’ll join me this Tuesday at 6:45 pm for Restorative Yoga at Pause Yoga and Pilates for Restorative Yoga!

All classes, memberships and packages are 20% off at Pause through the end of December, so this is the perfect time to get started with your Restorative Yoga practice. Use CODE: 20OFF

It’s getting a little cooler outside, and with some snowy weather on the horizon many folks will opt for walking or running on a treadmill instead of getting outside.

Before you make that switch, read this blog… and you might just change your mind!

Optical Flow

When you walk outside, you experience what we call “optical flow.” That is a fancy way of saying when you move forward, your eyes and brain expect things around you to move backward.

“Expect” being the key word here. When we don’t sense the objects around us moving backward as we move forward, our brain doesn’t like that. You get a signal that says, “this isn’t right.”

And that creates systemic, low-level tension in your body.

You don’t want that!

Ground Sense

Similarly, when we experience objects moving past us as we move forward, it helps to sense the ground at the same time. When we walk (or run) on a treadmill, the floor sense is altered by the tread moving backwards relative to you.

This requires that your body do more pulling with hip flexors and back extensors instead of pushing with glutes, hamstrings, and abs.

Walking over ground, outside, restores normal balance and patterning so your body can experience push instead of pull…because too much pull when walking does what? Say it with me…

Creates systemic, low level tension in your body.

Are we seeing a theme here?

So What Should I Do?

Bundle up and go outside! Of course be careful of ice etc, but getting outside whenever you can is so beneficial.

While you’re out walking, notice things move past you in your peripheral vision as you sense your feet on the ground. Especially sense your heels if you are walking (and occasionally sense heels when running, too!)

You may notice it’s harder for you to sense objects moving back as you go forward on one side vs the other, e.g. it may be obvious on the right, but hard to sense on the left.

In this case, focus on feeling weight through your left foot, especially heel, as you notice objects move back on the left.

Correcting this imbalance can correct a lot of patterns that contribute to pain syndromes.

If you are avoiding ice or extreme weather and you choose to walk or run on the treadmill, don’t fret! Just walk around inside afterwards working on optical flow and ground sense as mentioned above to restore some balance.

One of the big walking “problems” I see is people being a little stiff in their torso, i.e. they can’t rotate! Chubby Checker would be so sad to see it 🙁

This usually results from the back being too arched, and the lower ribs in front not being able to soften down. From this position, you can’t rotate. If you can’t rotate, your walking and breathing become inefficient, and things start to hurt after a while.

In the previous post, “free your arms,” I discussed the importance of letting your arms move freely. But this only truly happens if your torso can rotate freely, because your arms just hang off your torso (picture Ace Ventura after getting a bunch of darts in his arms. Do I have to show the gif again? Okay here it is, for your viewing pleasure.)

So how do you let your torso rotate?

First thing to do is exhale and let your lower front ribs soften down. Check out this video on how to do that.

Once you’ve established that, sense the area at the bottom of your sternum or breast bone, the bony part in the center of your ribcage (the purple area in the picture below).

This is called your “xyphoid process” which is a fancy name for the lowest tip of your sternum bone.

To allow more twist, once ribs are exhaled and softened down, visualize rotation from this point, the xyphoid process.

Essentially, your torso should rotate in the opposite direction of your pelvis. So, as the center of your chest turns to the right, your pant zipper should turn to the left, and vice versa.

For most people, it will be harder to keep your pant zipper to the left as your sternum turns to the right because our anatomy, our brains, and our environment makes it preferable for us to keep our pelvis facing to the right (pant zipper pointing to right) and we balance that by turning our chest and torso to the left (sternum facing left).

So we need to work a little harder to get our pelvis to the left and torso to the right!

In this “harder” position, with left pelvis rotation (zipper to the left) and right trunk rotation (sternum to the right), your left leg is back and your right leg is in front, and your left arm is forward and your right arm is back.

If you try to think to hard about all this, though, you’ll probably end up walking kinda slow and stiff, which is the opposite of what we want!

That’s too “think-y” and walking is not managed with thought. It’s a very natural process that we have to allow rather than force.

This is why focusing on softening ribs down with complete, long exhales and noticing rotation at the xyphoid process is more helpful- it’s enough information to remind your body what to do without overwhelming it.

PRO TIP: For extra walking correction that will really get things moving in the right direction, try listening to some upbeat music while you walk! This taps into your body’s natural inclination towards rhythm, and walking is a very rhythmic activity when it’s going well.

Make sure the music has a really clear beat that’s easy to find. For some reason “Adore You” by Harry Stiles seems to work well. But hey, if Harry’s not your thing, you do you, boo.

Even Better- try wearing one headphone, in just your left ear! This increases awareness of our left side and helps restore balance by enhancing the left push-off phase of walking (pelvis to left, torso to right, left leg and right arm back) that tends to be harder. Sounds weird, works well.

Next month I’ll cover the 3rd factor that you need to walk better- Look! Where you’re going, yes, but there’s so much that our vision does to clean up walking…Stay tuned to find out how!