Great programs but why the disconnect?

disconnectAfter receiving basic information about the University of Ottawa Heart Institute’s Heart Wise Exercise program, presented at my yoga therapy training, I wanted to go back to learn more so paid them a visit earlier this week. Theirs is a program that helps to connect patients who have been through initial rehab programs after diagnosis, illness, surgery from heart disease, to community-based exercise programs and fitness professionals. It served primarily Ottawa but over the years has expanded in/around Ontario and a little into Quebec.

I mentioned a program in Alberta that I’d found on the internet a year or so ago. In Alberta the Prescription to Get Active Program allows you to visit your doctor, receive a ‘prescription to get active’ and then find a facility in your community offering all kinds of activities from walking, strength training, yoga, cycling, swimming, dancing, etc. The ‘prescription’ allows for free access (often a series like a 10-pass visit, free month, etc.) to get you started.

I often reference the excellent program the province of BC provides to health care providers and those living with chronic pain. The Pain BC program is one of the of the best (well, the only one of its kind I know of) in Canada in terms of information, resources and programs.

It’s too bad all these programs are rather piecemeal and for the most part unknown across Canada, rather than being coordinated. I give great credit to the people and work done to provide them.  It’s just our government or overriding systems that seem to be unable to provide the coordination, or funding or whatever might be needed so everyone can access them.

Regardless, for my Canadian friends and followers, feel free to check them out!

Links above, but for easy reference click on any of these links:

“Are we there yet?”

squishedSummer has officially begun and soon many will be on their long-anticipated holidays. Most likely, it will involve some travel. And at some point the dreaded ‘are we there yet?’ You might think it to yourself or maybe your little travel companions repeat the phrase. On the hour. Time seems to drag. on. forever.

Why is it we dread the getting to, and coming back from, our trips?

Sure there can be unexpected delays or surprises that inevitably happen. But typically it’s the thought of sitting in our vehicle driving for 4, 8, or 12 hours to our destination. Or being crammed into the airplane for hours on end. Uncomfortable, to be sure. Not only being seated for so long but also waiting to eat on someone else’s schedule or getting to the bathroom when the need arises.

Most of us sit, for hours, all day long. Why then, does it feel different or more noticeable when we’re traveling? In an airplane, it’s not so easy to move around, to shift in our seats, when discomfort arises. In our cars, perhaps it’s a little easier with more room and not so many eyes watching us.

On most any day, we tend to listen to the hunger and thirst signals our body sends us, while other ‘discomforts’ such as simply moving, tend to be ignored. Why do we respond to some and not to others?

Which discomforts do we choose to tolerate? 

Little kids fidget, move, express themselves all the time. Until they’re told not to.

How might it feel …

to move and shift, and stretch and dance as you like, when you like? As you feel the need or desire to do so? At any time. Any place. Before, the discomfort pretty much commands that you do so?

When you are uncomfortable, how do you respond? Do you respond?

Hmmmmmm……

 

Low Back Pain: GAPS between Guidelines and Practice

 

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Continuing with the second of three papers recently published in The Lancet regarding Low Back Pain. What guidelines are already in place, what’s actually occurring in practice and suggested solutions going forward.

What’s striking to me is the

clear evidence of substantial gaps between evidence and practice, that are pervasive

A few years after delving into this, I am still scratching my head how far behind we are in our medical and clinical practice given the evidence. Yet, I’m hopeful that as more and more of this gets into the public domain, much-needed momentum will begin to close the GAP. Particularly with the crisis we find ourselves in, the growing epidemic of opioid use which is literally, killing people.

What are the treatment guideline GAPS, as outlined in the paper?

Below are

study results of clinical practice and highlights the disparity between ten guideline recommendations and the reality of current health care.

Guideline Message: Low back pain should be managed in primary care.

Practice: in high-income, low-income, and middle-income settings, people with low back pain present to emergency departments or to a medical specialist.

Guideline Message: Provide education and advice.

Practice: in high-income, low-income, and middle-income settings this aspect of care is rarely provided.

Guideline Message: Remain active and stay at work.

Practice: in high-income, low-income, and middle-income settings, many clinicians and patients advocate rest and absence from work.

Guideline message: imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain.

Practice: although such specific causes of low back pain are rare, in high-income, low-income, and middle-income settings, imaging rates are high.

Guideline message: first choice of therapy should be non-pharmacological.

Practice: surveys of care show that this approach is usually not followed.

Guideline message: most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction).

Practice: worldwide these ineffective treatments are still used by the professionals who administer physical therapies.

Guideline message: due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged.

Practice: these medicines have been overused in some, but not all, high-income countries; low-income and middle-income countries seem to have very low rates of use.

Guideline message: interventional procedures and surgery have a very limited role, if any, in the management of low back pain.

Practice: these approaches are widely used in high-income countries, little evidence on their use is available for low-income and middle-income settings.

Guideline message: exercise is recommended for chronic low back pain.

Practice: clinician treatment preferences and health-care constraints limit uptake.

Guideline message: a biopsychosocial framework should guide management of low back pain.

Practice: the psychosocial aspects of low back pain are poorly managed in high-income, low-income, and middle-income settings.

As you can see, what’s recommended is not what’s being offered to people for treatment.

Though first line care is meant to be non-pharmacological,

a study from the USA showed that only about half of people with chronic low back pain are prescribed exercise. In Australian primary care and in the emergency department setting in Canada, the most common treatment is prescribed medication.

Then, there are the rates of imaging, even though it has a limited role to play (see previous post).

39% in Norway, 54% in the USA, 56% in Italy as three examples, presenting patients to emergency rooms are given imaging.

Even worse, opioids. Though data for effects of opioids for acute low back pain are sparse,

one study showed that they were prescribed for around 60% of emergency department presentations for low back pain in the USA.

And,

More than half the total number of people taking opioids long-term have low back pain though NO randomized controlled trial evidence is available about long-term effects. Well, we can see some of the short-term effects taking place across our countries at the moment.

In terms of surgery, which has “a limited role for low back pain”,

studies from the USA, Australia and the Netherlands show frequent use of spinal fusion.

So the waste to our healthcare system is apparent, but the bigger cost is what’s happening to the people who are provided these treatments that have shown to have little success. They seem stuck in what seems a never-ending loop of pain.

Key messages:

“Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments, routine use of imaging and investigations is not recommended.

Little prevention research exists, with the only known effective interventions for secondary prevention being exercise, combined with education, and exercise alone.”

Where do we go from here?

“Promising solutions include focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.”

Current guidelines need to be utilized which we clearly see, they are not.  There needs to be better integrated education of health-care professionals including a change to the clinical-care model. Revamping the “current models of health-care reimbursement, which reward volume rather than quality”. Integration of health-care and occupation interventions so we can get people back to work and back to their lives. Changes to compensation and disability policies. Finally, public health interventions to change public’s beliefs and behaviors.

Which brings us to the last of the 3 papers, Low back pain: a call for action, up next on the blog.

Low Back Pain – What works and what doesn’t, according to the research.

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Previously I wrote about the first in a series of published papers in the Lancet regarding the global burden of disability caused by low back pain and why we need to pay attention. You can read it here.

The second paper, “Prevention and treatment of low back pain: evidence, challenges and promising directions” contains a lot of information so today I’ll begin with prevention and treatment while the next blog post will further explore current guidelines vs. what’s actually utilized in the global medical community.

My hope is perhaps you’ll come to see for yourself there are promising directions for those disabled and suffering from low back pain.

I. Prevention

Most of the widely promoted interventions to prevent low back pain do NOT have a firm evidence base.

A surprising statement, isn’t it? These include what you have likely been told over and over again to do, yet evidence of their success is not there. Strategies about workplace education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices. How often have you heard about most or many of these in terms of how we might prevent low back pain?

What then, seems to work?

II. Treatments

First, is the recommended use of a biopsychosocial model.

I suggest most of the general public has never heard of this term or model of care. I surely didn’t just a couple years ago when I was first started to dig into the overarching problem of chronic or persistent pain that affects so many people.

What is this? Well, as often defined it encompasses “a dynamic interaction among and within the biological, psychological, and social factors unique to each individual.”  My emphasis on the ‘unique to each individual’, as that’s turning out to be an important piece of the complexity of pain.

Second, greater emphasis is needed on

  • Self-management
  • Physical and psychological therapies
  • Some forms of complementary medicine,

Along with less emphasis on

  • Pharmacological and surgical treatments.

What’s actually being utilized in our clinics?

Surprisingly, the treatments with less emphasis and effectiveness = pharmacological and surgical treatments.

Countries such as Denmark, the USA, and the UK do have guidelines around this. They are supposed to utilize exercise and a range of other nonpharmacological therapies such as massage, acupuncture, spinal manipulation, Tai Chi, and yoga.

Clinicians are meant to provide people with

  1. Advice and education about the nature of their pain;
  2. Reassurance that they do NOT have a serious disease and their symptoms will improve over time;
  3. Encouragement to stay active and continue with usual activities.

Self-Management

I understand even the notion of engaging in movement and exercise is difficult for people who are experiencing pain. How do you keep active when you are in pain? How much does advice, education, reassurance really help? People typically go to their health care providers and want something to ‘fix’ the problem. Not more advice. However, evidence shows this does help. And, evidence shows that the pharmaceuticals and surgeries we’ve come to rely on, don’t. In the long-term, particularly. If they worked, we wouldn’t find ourselves in this predicament.  Understanding that you have a part to play, in getting better, is critical. 

Movement or Exercise Therapy

Going back to the problem of trying to move, when you’re in pain. Something that people may or may not be familiar with is the term graded exposure. Basically, it means you start where you can, and gradually, over time, work to increase your overall capacity.

I tell my clients it will help to do even the smallest of movements. Use your imagination and even just visualize movement if you must, but you CAN start somewhere. Move your feet, or hands, or arms an inch, if that’s what you can do today. Just begin.

It has been shown to be useful if you can tie in your exercise or movement with something you want or need to do, rather than just some kind of exercise that is not motivational for you.

It’s not really so much WHAT you do, but that you DO something.

“Since evidence showing that one form of exercise is better than another is NOT available, guidelines recommend programmes that take individual needs, references, and capabilities into account in deciding about the type of exercise.

I use tools that yoga offers and work to help keep clients joints moving in all the many ranges of motion they might need in their life. This does not mean they need to have a life-long love or commitment to yoga.

Yet, yoga does offer an important first step of building awareness and subsequently using gentle movement, breath awareness, and tools to ‘ease into a movement’ that may have be feared in the past. People can learn to calm their nervous system, work in a safe pain-free range of motion (or not increase pain). From there we work to build stability strength and power in whatever it is they want to do … be that swimming, walking, biking, skiing, playing with kids, sitting at a desk all day. Whatever it is they want to do in their life.

Passive Therapies

It should be noted that some guidelines DO NOT recommend passive therapies, such as manipulation or mobilization (think chiropractor, massage, acupuncture). Some guidelines consider these short-term options, optional. The same goes for other passive treatments received in a physical therapists office like ultrasound, nerve stimulation, etc.

Though these passive types of therapy may help to temporarily feel better, they often have many returning again and again, becoming dependent on them for relief. Much of the current research shows the need to get a person ‘involved’ in the treatment. Get their brain and nervous system participating in movements or other practices, so passively ‘being worked on’ might not be a long-term solution.

Psychological Therapy

Guidelines also recommend Cognitive Behavioral Therapy (CBT), progressive relaxation and mindfulness-based stress reduction (MBSR).

This again is where yoga can play a part in terms of relaxation. I’ll often incorporate strategies from MBSR when working with clients.

Pharmacological Treatment

Guidelines now recommend pharmacological treatment ONLY following an inadequate response to (the above mentioned) first line non-pharmacological interventions.

Paracetamol was once the recommended first-line medicine for low back pain; however evidence of absence of effectiveness in acute low back pain and potential for harm has led to recommendations against its use.

Health professionals are guided to consider oral non-steroidal anti-inflammatory drugs (NSAIDS), taking into account risks …  and if using, to prescribe the lowest effective dose for the shortest possible time.

Routine use of opioids is NOT recommended, since benefits are small and substantial risks exists…

The role of gabaergic drugs, such as pregabaline, is now being reconsidered after a 2017 trial showed it to be ineffective for radicular pain … guidelines generally suggest consideration of muscle relaxants for short-term use, although further research is recommended.

Surgery

The role of interventional therapies and surgery is LIMITED and recommendations in clinical guidelines vary.

Recent guidelines DO NOT recommend spinal epidural injections or facet joint injections for low back pain… they DO NOT seem to provide long-term benefits or reduce the long-term risk of surgery and have been associated with serious adverse events.

Benefits of spinal fusion surgery … are similar to those of intensive multidisciplinary rehabilitation and only modestly greater than non-surgical management.

UK guidelines recommend that patients are not offered disc replacement or spinal fusion surgery for low back pain.

For spinal stenosis … patients tend to improve with or without surgery and therefore non-surgical management is an appropriate option for patients who wish to defer or avoid surgery.

So why the GAP between evidence and practice?

Stay tuned and we’ll look to see how this is played out and why it’s imperative that we change it.

 

 

 

Low Back Pain – Extremely common, complex in nature and most often, not treated effectively

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Last week I wrote briefly about a recently published paper in the Lancet, picked up by the news in the UK, here, here, here, and here. Today, I’ve seen an article in the USA. So, far, one report that I can find, in Canadian news.  One headline from Monash University in Australia goes so far to say:

Global burden of low back pain – a consequence of medical negligence and misinformation

As mentioned, I said I would break down why I believe this is so important. The first paper (three in the series) is “What low back pain is and why we need to pay attention”.

Why should all of this matter to you? Why do you need to pay attention?

The median 1-year period prevalence globally in the adult population is around 37%, so chances are you or someone you know is affected.

And, what’s even more important, is

the way we have been treating people isn’t working.

“Low back pain (LBP) is now the number one cause of disability globally.”

There are a LOT of people who experience chronic or persistent low back pain.  On a purely personal note, I would say it is the most prevalent ‘problem’ people tell me about when they turn up at my yoga classes.

“Rarely can a specific cause of low back pain be identified; thus, most low back pain is termed non-specific. Low back pain is characterized by a range of biophysical, psychological, and social dimensions that impair function, societal participation, and personal financial prosperity.”

In other words, it’s complex.

Of course, there is always a need to rule out those cases where there is specific causes.

“but, this is for less than 1% of those presenting with LBP. Known causes may include vertebral fracture, axial spondyloarthritis, malignancy, infection, or cauda equine syndrome (very rare).”

So if any of these are suspected by presenting symptoms, a clinician is well advised to do testing, imaging, etc. for what are often referred to as ‘red flags’.

If these are ruled out or if you’re not suspect for these specific causes, what then?

“Most adults will have low back pain at some point.  It peaks in mid-life and is more common in women, than in men.”

“Low back pain that is accompanied by activity limitation increases with age.”

“Most episodes of low back pain are short-lasting with little or no consequence…”

“But recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences.”

It’s highest in working age groups so the effect to the workforce is impacted. People unable to work, earn income, the possibility of early retirement. “In the USA, LBP accounts for more lost workdays than any other occupational musculoskeletal condition”.

Then there’s a person’s identity. Consequences such as loss of independence, ability to fulfill expected social roles can be impacted. Common themes of worry and fear are identified, along with hopelessness, the strain on families, social withdrawal, job loss, and there’s the navigating through continual healthcare encounters.

Most studies underestimate the total costs of LBP, but the economic impact is comparable to other high-cost conditions like cardiovascular disease, cancer, mental health and autoimmune diseases.

Most cases are resolved within 6 weeks, however, there are risk factors for recurring episodes. For people with other chronic conditions like asthma, headaches, diabetes. Those with poor mental health are at increased risk, etc. As one example, a study of Canada’s population with 9909 participants, found that “pain-free individuals with depression were more likely to develop LBP within 2 years than were those people without depression”.

Lifestyle factors are also at play. Smoking, obesity and low levels of physical activity are associated, although independent associations remain uncertain.

Which brings us back to it being complex. There are multiple contributors, “including psychological factors, social, biophysical, comorbidities and pain processing mechanisms.”

We can see the complexity when there is a continual increase of those affected, an increase in our health care expenditures and by the recent opioid crisis that is literally taking people’s lives.

It also seems whatever we’ve been doing in terms of treatment doesn’t seem to be working.

Why is that and what needs to be changed?

Tune in next week… where we’ll get to the second paper, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

Note:   For those interested, all references/studies can be found in the Lancet paper, here.

What might be useful skills?

Funniest thing I read the other day.

Being flexible ain’t all it’s cracked up to be

Doing the splits is not exactly a useful skill.

– Painscience.com

I’ve written about this before, here. But I think it’s important to talk about again.

People associate yoga with flexibility.

I do associate the word flexibility with yoga, but it’s in how we apply flexibility to our life.

That is, we have lots of choices available to us.

People often get stuck and then their choices become smaller, and smaller, and smaller… until they feel something a little like this; boxed in.

stuck

What I’m really looking for is this:

Freedom.

Do you have freedom, to do what you want in your life?

Do you have the freedom to BE you?

Skills that may aid in this might be strength. Physical strength if you want to move around in the world. Be able to go jogging, walking, cycling. Even to simply pick up and play with your kids/grandkids.

Maybe you are an office worker or writer and need to sit a lot of the day. What skills might be useful to do that?

A skill may be the ability to voice your opinions at work?

Or the skills required to get a good night’s sleep, so you have the energy for the coming day.

A useful skill may be noticing what creates tension in your body.

Try sitting in a dentist chair for any length of time and notice how you feel?  A sore jaw, perhaps, makes sense. But what might your shoulders feel like? Or your leg muscles? Imagine doing this, unknowingly creating tension throughout the day, and what it might create? Pain, fatigue, stiff or sore muscles.

Yoga, is all about the noticing.

Which helps guide our life, …

out of the box, and toward spaciousness and freedom.

 

 

 

 

Just, … breathe

People often sit at their desk, laptop, TV, or plugged into a smartphone with their earphones in. Listening to music, podcasts, videos on YouTube, working, or whatever.

As an experiment, the next time you put your earphones on, don’t ‘listen’ to anything except your breath.

It may not be as noticeable if you’re on the bus, driving, in an airport or a similar noisy environment. But, still, I think you’ll find it to be … telling.

How are you breathing?

Are you breathing fluidly?

Is there equanimity on the inhale and exhale. Or is one shorter or longer than the other?

A pause in between may be good. But do you find that you’ve actually stopped breathing? As in not breathing altogether of course, but that your breathing is not fluid. Easy. Continuous. That there is a long pause, perhaps, between the two. That you fail to begin the inhale, until long after the exhale.

  • Why might that be?
  • How do your neck muscles feel, while you’re noticing ‘this’ breath?
  • How does your torso or trunk feel?
  • How does your abdomen/belly feel?
  • Do you notice or feel anything at all?
  • Do you sense anything?
  • What might this noticing, this awareness tell you?

In the meantime, try this.

Inhale, and exhale, along with the shape below.  Expansion, contraction.

breath

I’m curious to hear of your experience.

I can say for sure, I noticed a few things about my own breathing patterns.

When there is quiet, what do I hear?

(Though we’re in the midst of a cold winter, I find I can ‘listen’ more clearly to my breath when swimming or floating in water, similar to listening with earphones in as above. Or if I submerge myself in bathwater. So choose what’s best for you, whatever might be your season.)

Please feel free to comment, in the space below.

 

What can you do today?

Most of the time I’m not sure where I’m at with my practice.

(I tend to substitute ‘my practice’ at any given time with ‘my life’, to get to the bigger picture).

  • Am I doing enough?
  • What should I be working on?
  • Is there enough time in the day?
  • What comes first?
  • What’s most important?

I used to get, oh, so bogged down in the details. I would be stuck because there were so many areas I needed to work on, I didn’t know where to start.

What I’ve learned over the past 3-4 years in looking at the research, the evidence about movement, manual therapy, yoga, etc. it’s become clear to me it’s not so much what I choose to do

… but that I choose to DO something.

Today I will go for a skate. Hopefully, I will remember to do a few useful stretches / movements before I begin. I know that doing these will be of benefit to me. Particularly in the cold weather and, well, because I’m getting older.

Canal

When I feel the muscles in my back, shoulders, and face tighten from the cold I will try to remember to release some of the tension there. Soften.

I will try to remember that LESS is MORE.

I’ve only been skating once this year, so it probably doesn’t make sense for me to skate the WHOLE canal.

Listen to the whispers that tell me when I’m feeling fatigued.

It is enough.

Sit back down. Unlace my skates. Grab some hot chocolate and call it a day, … well done.

What will you do, today?

 

 

Yoga Tools – Open Your Mind

I’m going to challenge you to change things up this week. Whatever you think you should be doing, (in a movement, in your posture) whatever you’ve been told to do… do the opposite.

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As an example, while you’re sitting during the day:

  •  If you have a tendency to hold yourself rigid, perhaps with your shoulders pulled back, chest puffed out front, sitting up nice and tall, as some would say ‘good posture’, allow yourself something different. Perhaps slump a little, let the upper back round a little, feel as if you can soften the area between your collar bones, let your belly be soft and full when you breathe. RelaxI’m not saying this is what you need or you should sit this way all day. But try it for a few minutes and notice what you feel.
  • If you tend to be someone who is generally in a slumped position when sitting, try the opposite. Feel your sitting bones on the bottom of your chair, perhaps even pushing them into your chair slightly. Think about sitting tall, imagining your head feeling light above your shoulders, it lifting towards the ceiling. Collarbones wide, shoulder blades down your back.  Notice what you feel.

Though this is only one example. You might try this way of being, or doing, in a multitude of ways.

In yoga, do you always exhale when forward bending and inhale on the reverse? Try changing it up and see what you feel. What do you notice?

Experiment with doing the opposite of what you think is right for you, what you’ve been told is right for you and see how it goes. If you like, comment below so we can take the conversation further.

 

Yoga Tools – Rest Easy

Life is not easy. For any of us.  There is more than enough to do, day in and day out. Stressors at work, at home or elsewhere.

So cut yourself some slack. Give yourself permission to rest. 

restStart with just 5 minutes.  Do this at least once a day. Do it twice if you like. But do it consistently.

You might want to set a particular time for this. Perhaps at mid-day, or early evening. It’s not often you need to rest first thing in the day and this 5 minutes isn’t meant for sleeping, so not too close to bedtime either.

  1. Either lie down or sit in a comfortable position (*see below for IMG_9231.JPGspecifics). It’s preferable to lay on the floor but if you’re unable to do so, a bed or sofa is fine.
  2. Set a timer for 5 minutes.
  3. Close your eyes or soften your gaze.
  4. Begin to breathe in and out through your nose (close your mouth).
  5. Be here for 5 minutes, just breathing naturally. Don’t try to change anything about your breath.
    • Notice where you feel your breath. It might be most noticeable in your nostrils, maybe in your chest or perhaps your abdomen.
    • Notice how your breath is moving. If there’s any particular quality to it such as smooth, interrupted, easy, strained.
    • Then just breathe. And just notice.
    • If your mind wanders, as it’s likely to do, just bring your attention back to your breath. Feel where it’s moving through your body, where you notice it. Try not to judge the wandering of your mind as anything either good or bad.
    • And just breathe. And just notice.
  6. When the timer goes off, slowly open your eyes. Roll over and stand up.

Notice what you feel. Mentally or physically make a note of what you experienced or noticed.

Keep practising for a week.

Check in with me next Tuesday and we’ll expand on this practise.

If… you can’t find 5 minutes in your day? You might want to look at that.

If you have any questions or comments, post them below.

* Positioning if seated

  • Sit forward on a chair so your back is not touching the back upright portion of the chair.
  • See if you can feel your ‘sitting’ bones (ischial tuberosities) and let your weight be supported there.
  • Have your feet planted on the floor, hip-width apart.
  • Hands comfortably on your lap.

* Positioning if lying down

  • Lie on the ground, perhaps on a carpet or mat if available. If you have back pain, you may want to use a rolled up towel, yoga mat, etc. to slip under your bent knees for support.
  • Hands can be by your side or placed on your belly.
  • Notice the parts of your body supported by the hard surface of the floor (heels, hips, shoulder area, head).