Tuesday 14 July 2015

Breathing and Proper Techniques for Pelvic Floor Rehabilitation

Pelvic floor rehabilitation employs techniques and procedures that aim at improving the function of the pelvic floor. The rehab program focusses on improving the strength and maintaining optimal tone of the pelvic floor.

The pelvic floor, also know as the pelvic diaphragm, is a sheet of muscles, ligaments and connective tissue that extends from the tail bone to the pubis. It forms the base of the body’s cylindrical core. The core is surrounded by abdominals and fascia, which serve alongside deep superficial back muscles. Diaphragm forms the dome of this core. The muscular mesh spans the entire pelvic outlet and separates the pelvic organs from the perineal region.

The pelvic floor musculature, by virtue of its attachments to the anal and bladder sphincters and vagina, is responsible for maintaining urinary and fecal continence, as well as vaginal tone during sexual intercourse. It supports the pelvic organs that include: the bladder, the intestine and the uterus. The pelvic floor offers counter pressure during activities that increase intra-abdominal pressure and bloating; thus, preventing organ prolapse. During labor, the pelvic floor offers resistance to the descending fetus causing it to rotate towards a vertex presentation during delivery.

Coordinated contraction and relaxation of the pelvic floor muscles is essential for a healthy back and lower body, as the muscles of the core are connected together. Pelvic floor dysfunction includes weak hypotonic muscles or tight hypertonic muscles. A weak pelvic floor cannot provide support to the pelvic organs and a tense muscle can be a source of constant pain. Pelvic floor dysfunction can result in bladder and bowel incontinence or urgency, organ prolapse, pain during intercourse, recurring unresolved low back pain, unspecified hip and pelvic pain. The pain can at times radiate to the groin, lower abdomen and down the legs. It can be severe enough to restrict your daily activities.

A dysfunctional pelvic floor requires a systematic approach to rehabilitation that will completely address the pelvic floor and the core. Techniques for pelvic floor rehabilitation include:

1. Deep breathing – The importance of breathing deep and slow has been stressed many times but has rarely been said in the context of pelvic floor dysfunction. Deep breathing or diaphragmatic breathing is an excellent way to alleviate muscle tension. When you breathe deeply your diaphragm moves up, your abdominal muscles move out, and the pelvic floor drops down in a relaxed manner. When you exhale, the diaphragm comes down, the abs move in, and the pelvic floor moves up. This coordinated muscle action is rarely done by a majority of people. Most of us breathe shallow and fast which does not allow the core to open up and the muscles to relax.

A few things to keep in mind while breathing deeply is to breathe in through the nose and exhale through the mouth with your lips pursed. Try and emanate a sound that resembles ‘S’ while breathing out and prolong it for as long as you can.

To begin with, come into a lying down posture with a pillow under the head and between the thighs. This keeps your knees slightly bent and relaxes the lower back. The room must be quiet and comfortable. Keep your hand on your belly. Close your eyes and breathe in deeply. Feel the belly move out during inhalation and move in during exhalation. Imagine that the air is entering your belly. The aim is to keep the upper chest muscles relaxed and let the diaphragm preform the action.

Once you have mastered diaphragmatic breathing exercises in a lying down position, practice them in sitting and standing positions. Do it for a minute initially and extend it to at least 5 minutes every hour. Diaphragmatic breathing should become our normal pattern of breathing.

In case you feel short of breath while doing this technique, stop and resume your normal breathing pattern. Repeat deep breathing after some time.

2. Watch your posture – The way you sit or stand affects the functioning of the core muscles. Slouched standing and sitting will curl your spine and your abdominals will be shortened. Therefore, your diaphragm is restricted and has less space to move. This increases the intra-abdominal posture which in turn increases the tension in the pelvic floor muscles.

Keeping your spine neutral will help you maintaining a normal lumbar curve. Keep your shoulders down and slightly retracted. The feet should be supported on the ground and hips and knees should be bent at right angles. Try to walk with your feet in parallel and avoid duck footedness and pointing your toes inward.

To stand correctly, each foot must be equally weighted. Try rocking forward and back a few times in order to find the right balance. Then, look straight ahead with your chin tucked in slightly and your shoulders down and back. This is the correct position for maintaining a normal lumbar curve.

Even while performing deep breathing, it is important to maintain a good posture so that diaphragm can traverse easily. A good posture while sitting or standing ensures that the deep abdominal muscles also come into play while doing diaphragmatic breathing. A good diaphragmatic movement will ensure relaxed pelvic floor muscles.

3. Kegel Exercises – These are a great way to strengthen weak and lax pelvic floor muscles. Hypotonic pelvic floor muscles cause urinary and fecal incontinence and bladder or uterine prolapse. The muscles become weak following a caesarean section, hysterectomy or any other abdominal surgery. Kegel exercises must be properly performed and learned under supervision, as incorrect technique can lead to pelvic floor dysfunction.

Start with this technique while passing urine. Try to stop the passage of urine for a few seconds and then resume. Slowly increase the hold count to 10 seconds. Once you get the feel of muscle contraction and relaxation, practice them in other positions too.

Do not contract your glutei or abs while doing this exercise. Concentrate only on the pelvic floor muscles. Do not hold your breath during this exercise, as it can increase your blood pressure. These exercises should not be overdone as the pelvic floor muscles are small and easily fatigued.

4. Biofeedback is a great way to ensure correct recruitment pattern of muscles during contraction. Uncoordinated muscle action can lead to muscle strain, even in the small pelvic floor muscles. This is usually done in the office settings, where you will be given an audio and visual feedback, while attempting to do a pelvic floor contraction. The doctor will encourage the correct pattern and help you identify the incorrect contraction. Biofeedback can also help you to distinguish between a tense and a relaxed state of muscles, which is very important for resolving the pelvic floor muscle tension.

5. Manual therapy can be applied to these small muscles as well. A doctor will first palpate the muscles to identify the areas of tension. Deep circular massage and myofascial release techniques can help break the fibrous bands that are the cause of the pain. Stretching of pelvic floor muscles can be achieved indirectly by performing hip adductor and hip extensor stretches. Combining manual therapy with warm packs to the perineal region offers immense relief in severe cases.

These techniques are very effective in resolving pelvic floor dysfunction and alleviating non-resolving back, hip and pelvic pain. So next time you get this pain, do not curl up. Instead lie down straight and visualise your pelvic floor muscles contract and relax. A healthy pelvic floor ensures a healthy core and a pain free body.

Pelvic Muscle Tension and Pelvic Pain

Pelvic floor muscle tension can often lead to non-specific chronic back and pelvic pain. An imbalance in the pelvic floor musculature, a cause of longstanding back pain or unrecognizable pelvic pain, may be hard to treat using traditional pain medications. The pelvic floor muscles, though small, can affect your entire bodies functioning. This article will discuss various causes for pelvic floor muscle tension and help you move towards remediation.

What is the pelvic floor?

To begin with, we must understand the formation of the pelvic floor or pelvic diaphragm. The pelvic floor forms the base of the cylindrical core that is situated in the centre of our body. The cylindrical core is formed by the diaphragm, above, and the pelvis, below. The muscles of the abdomen, the lower spine, the back, and the thoracolumbar fascia surround the cylinder, making it a closed compartment. The pelvic outlet is closed by a group of small muscles, ligaments and connective tissue and interspersed with small nerves that form a trampoline or a hammock shaped structure known as the pelvic floor or the pelvic diaphragm.

The main function of the pelvic floor musculature is to support the pelvic organs that include the bladder, the last part of the intestine, the rectum, and the uterus. Since the muscles of the pelvic floor have attachments with the bladder and the anal sphincters, the pelvic floor is responsible for maintaining proper bladder and rectal continence. Its attachment to the vagina gives it an important role during sexual intercourse, as it helps to relax and tighten the vagina. The pelvic floor also offers counter pressure to the descending fetus during the labor, which rotates it and causes the head to present first during normal vaginal delivery. In the end, a pelvic diaphragm with normal tone helps to maintain the intra-abdominal pressure by exerting an upward counter pressure. This is of great importance during activities that increase intra-abdominal pressures like lifting, coughing, sneezing etc.

What is pelvic floor muscle tension?

Pelvic floor muscles are just like other skeletal muscles in the body; they too can become taut and tense when overworked. A tense or hypertonic pelvic floor is referred to as pelvic floor muscle tension, wherein the muscles do not relax and remain tight and stiff. Just like hyperactive skeletal muscles, tense pelvic floor can also cause pain (which may radiate) as they too develop trigger points. Since these muscles are not visible, we rarely consider them as a potential source of pain when we feel discomfort radiating in the low back, legs or the pelvic region. As these muscles are connected directly or indirectly with every other part of the body, tension in this region can cause pain elsewhere too. For example, a tense pelvic floor can transmit the tension and pain through the cylindrical core to the muscles in the back. In this case, the patient will complain of chronic back pain that is unrelieved by painkillers or routine therapy.

Causes and symptoms of pelvic floor muscle tension

Recent studies have helped to identify activities that can lead to pelvic muscle tension. Let’s take a look.

· Kegel exercises, when performed indiscriminately, are a common cause of pelvic muscle tension. When these exercises are executed without proper guidance, they can lead to overactive and painful pelvic floor musculature.

· Incorrect posture, like slouched sitting, standing or sitting cross-legged for a long time, can also increase tension in the pelvic muscles. When standing for an extended period of time, the pelvic floor muscles are acting against gravity to support the pelvic organs. Additionally, slouched and cross-legged sitting keeps the muscles in a contracted state. A sustained state of contraction can be a major cause of tension in the pelvic diaphragm.

· Exercises that tone the tummy, like sit-ups and keeping the belly drawn in towards the spine (i.e. tummy tucking), keeps pressure in the abdomen high. Increased intra-abdominal pressure can take its toll on the pelvic floor. To counter the increased pressure, the pelvic floor muscles are contracting round the clock, which can increase their tension.

· Chronic constipation can also cause pelvic pain as hard bowel motions put a strain on the rectal attachments of the pelvic floor. Improper bowel and bladder routines or voluntary holding of urine and stools can keep these muscles tense for a long time, leading to pelvic uncomfortability.

· Pelvic pain caused from an infection or during menses can bring about involuntary tensing of the pelvic floor. Procedures such as hysterectomies and caesarean sections can cause formation of scar tissue and adhesions in the pelvic floor; this can become a source of pain later in life. Injury to the low back and hip can also cause pelvic muscles to tense up. Repeated physical abuse and physiological distress can also be a cause of tense pelvic floor muscles and non-specific back and pelvic pain.

· Syndromes associated with chronic pelvic pain include: irritable bowel syndrome, endometriosis, and interstitial cystitis or painful bladder syndrome. These disorders are all associated with non-relaxing pelvic floor muscles.

· Incorrect footwear and gait abnormalities can also cause pelvic floor muscles to tense up. The cylindrical core and the lower extremities form a kinetic chain. Abnormality at one point can reflect anywhere up or down the chain.

Symptoms of pelvic floor muscle tension include: unexplained and unresolved low back and hip pain, pelvic pain, urinary and fecal urgency, incomplete emptying of the bowel and bladder, and pain during and after intercourse. At times the pain may radiate to the groin and legs. The pain can be dull nagging or severe enough to impede one’s routine activities.

Experts in pelvic floor dysfunction can help identify tense muscles by palpating them. They can also locate the presence of hypertonic bands (i.e. overly toned tissue).

How to relieve pelvic floor muscle tension

Now that pelvic floor has been identified as a possible source of pain emanating to the lower body, its treatment has become well defined. Pelvic floor rehabilitation is the gold standard for relieving pelvic floor muscle tension. Most of the treatment is aimed at removing the causative factors, which will help break the vicious cycle of pain-spasm-pain.

1. Stop doing Kegel exercises – If you have been doing them for a while, it’s a good idea to take a break. The pelvic floor muscles need rest. It is also beneficial to stop doing core strengthening exercises, cycling, high impact workouts, and deep squats, as these require a sustained contraction of the pelvic floor.

2. Pelvic floor drop – This is good technique to let go your pelvic floor muscles and help them relax. Locate a calm place around you for this exercise. You can stand, sit or lie down. Relax your body by taking a few deep breaths. Now close your eyes and take a deep breath. Visualise the air passing through your body and going out through the pelvic outlet. Relax the pelvic floor muscles to allow the air to pass. Just like when you pass urine, the pelvic floor muscles relax. Attempt to reproduce this same feeling.

3. Stretching of hip flexors, adductors and glutei can also help stretch the tight pelvic floor muscles as they are attached

4. Applying warm packs to the lower abdomen or between the legs can also help relax the pelvic floor muscles.

5. Down training or reverse-Kegel exercises are other good ways to relieve muscular tension. Kegel exercise increases tension by keeping the pelvic muscles contracted. To perform reverse-Kegel’s, start by lying down on your back; contract your pelvic floor muscles as if attempting to stop the passage of urine. Feel the tension in the muscles. Now, slowly relax the muscles. You will feel the tension go. Try and appreciate the difference between a contracted and relaxed pelvic floor muscle. Once you have achieved this, begin to imagine that your pelvis is expanding. Imagine that your tailbone and pubis are moving apart, thus lengthening the pelvic diaphragm. Take deep breaths while doing this. Once you have mastered this feeling lying down, try and see if you can do it sitting and standing. Make sure to not tilt your pelvis during this exercise.

6. Deep breathing or diaphragmatic breathing is great to relax and oxygenate your pelvic floor muscles. When you take a deep breath, the diaphragm moves down, the abs move out, and the pelvic floor muscles move down and relax. While exhaling, the reverse happens. Make sure to do at least 4-5 deep breaths every 2-3 hours. They will not only increase the oxygen supply to all the muscles but also relieve muscle tension throughout the whole body.

7. Myofascial release and soft tissue massage can help release the myofascial bands and hypertonic muscle tension. Try using a foam roller or a soft ball and roll lightly on the affected areas while relaxing your muscles.

8. Biofeedback can help patients to identify the difference between a contracted and a relaxed muscle. It can also be used to teach coordinated relaxation and contraction of the pelvic floor muscles.

9. Get your constipation treated. Drink plenty of water and consume fresh fruits rich in fibre to relieve constipation. Avoid eating rich meats like beef and pork that are harder for the body to digest. Try and achieve a good bowel bladder routine.

10. Vaginal dilators can also be used to relax the vaginal muscles. They must be used with lubricators. Avoid penetrative sex when pelvic floor muscles are tense, as it will increase pain and spasming around the vaginal area.

11. Postural correction, like sitting or standing with the back supported, avoiding slumped posture, and wearing comfortable supportive footwear, can also help resolve pelvic pain and pelvic floor spasming. Try and lie down whenever possible if you feel particularly uncomfortable: it puts these muscles in a gravity-eliminated position. Sitting on pelvic support cushions can also help mitigate pain to some extent. Avoid sitting on rubber tubing.

12. Last but not least, do not stress or get anxious over trivial issues. Stress and anxiety increase the overall tension in the body, which includes the pelvic floor muscles. Practice meditation, progressive relaxation and visualization techniques for whole body muscle relaxation.

If you are plagued by unexplained pain in the lower part of your body, be sure to get evaluated for pelvic floor myalgia. Once diagnosed, embark on a supervised rehab program to get rid of the pelvic floor muscle tension and the pelvic pain.

Sunday 12 July 2015

Yoga and Meditation for Women’s Health

Today, there is a wave of yoga and meditation going around the world. We get to read and hear a lot of information about yoga, meditation and their benefits from newspapers, magazines and televisions touting. Worldwide many research studies have been conducted to ascertain the significance and dynamism of these ancient cultures. Now let us see what is yoga and meditation.

With expansion in diversity across the world, it has become challenging to set forth a single, common definition of yoga. The word yoga comes from an ancient Indian language, Sanskrit. It has been derived from the word “yuj”, which means to unite or to integrate. The crux of yoga is in harmonizing our body with mind and soul by means of various breathing exercises (pranayama), yoga postures (asanas) and meditation. Let us move further to understand the meaning of an integral part of yoga i.e. meditation. As our life is moving faster without relaxation, we oftentimes tend to find calmness and want to unplug ourselves to give our minds a rest. Meditation is one such way to unwind and calm our mind.

Yoga and meditation have their roots in history that goes back to 1000s of years. The researchers have successfully demonstrated that these ancient practices are like an asset to human being. In yoga, body is treated with utmost care which positively impacts our health and leads to serenity.

In this post we will be talking about the health benefits of yoga and meditation specifically for women. So for all the ladies out there, just adding few postures to your everyday exercise routine can help you achieve potential health benefits. And these benefits will be at physical and mental level too! Following are the various positive health impacts of yoga and meditation on women’s wellness.

·      Stress, anxiety and depression
We all experience stress, anxiety and feel panicky time to time in our life. However, women are reported to be more vulnerable to stress, anxiety and depression. Anxiety and Depression Association of America reports women are twice as likely to experience anxiety disorder as men [1]. Generalized stress, anxiety and depression if not taken care of, may lead to panic attacks and phobias in future. Yoga has apparently been proven as an effective method to manage stress that can improve the emotional disturbance in women. A one year study conducted in 2009 showed that women participating in twice weekly yoga classes (Ashtanga yoga exercises) of 90 minutes for two months demonstrated significantly lowered anxiety. The researchers also asserted that yoga can be considered as an alternative for medical therapy for the treatment of anxiety disorders [2]. Also, practicing meditation on a regular basis reduces anxiety and provides emotional health boost in women [3].

·      Weight loss
Most women at some point struggle with their weight gain. There are many reasons why women put on the pounds. The predominant factors are sedentary lifestyle, genetic composition or environmental influences that cause weigh gain in women. You might know that sometimes there is unintentional weight gain due to hypothyroidism, chronic depression, menopause, Hashimoto’s diseases or postpartum depression. Yoga poses have magical powers that help women in shedding those extra pounds and lead a healthy life. A study conducted by researchers at the Fred Hutchinson Cancer Research Center in Seattle included 15,500 middle‑aged healthy men and women as participants. It was inferred that regular yoga practice indeed strongly helped people lose weight or at least attenuate weight gain [4]. Yoga poses like half‑moon pose, warrior pose, chair pose, tree pose, forward bending pose and sun salutation help women in weight loss and feel healthy.

·      Backache and posture problems
Do you experience gnawing back pain even after doing light physical activities? Then yoga is a powerful remedy for your back problems which improves postures too. General reasons for back pain in women include sitting or standing for long hours, incorrect posture, lack of exercise, obesity or weak back muscles. The researchers from Korea carried out a study in pre­‑menopausal women with chronic low back pain. The women practiced yoga three times a week for 12 weeks. It was observed that yoga reduced the symptoms of back pain and improved back flexibility in study participants [5]. You can strengthen your back muscles by practicing simple yoga postures such as triangle pose, knee‑to‑chin pose, cat stretch and standing spinal twist pose.

·      Osteoporosis and osteoarthritis
Osteoporosis (reduction in bone density) and osteoarthritis (inflammation and degeneration of joints) in knees, wrist, fingers, toes and hips are commonly occurring painful disorders in women due to low bone mass. Osteoporosis and osteoarthritis can impair your ability to walk and can cause prolonged or permanent incapacity. Most doctors prescribe heavy dose medications for such conditions. Yoga appears to be a natural and economical way to build bone mineral density. A clinical study published in European Journal of Physical and Rehabilitation Medicine in 2010 proved yoga as a successful alternative physical therapy for the rehabilitation of osteoporotic women [6]. The effective yoga poses for bone disorders include mountain pose, Warrior pose II, bound angle pose and staff pose.

·      Menstrual problems and post‑menopausal hormonal imbalances
A normal menstrual cycle is of 28±7 days. But, your menstrual cycle is not always regular. You may experience pain, cramps and heavy blood flow during menstruations which may lead to anxiety and depression. The irregular and painful periods are majorly related to the hormonal imbalances. The factors that trigger irregular or missed menses may include obesity, excessive dieting and exercise, stress, medications, polycystic ovarian syndrome and age. A natural way to cure menstrual problems is yoga and meditation. The safe and simple yoga poses can heal problems like hormonal menstruation disorders, heavy blood flow and painful menses. Three yoga poses called cobra pose, cat pose and fish pose are known to be very effective in reducing the severity and duration of menstrual pain [7]. It has been proven that Yoga Nidra (relaxation therapy) reduces the psychological problems like anxiety and depression associated with menstrual disorders [8].
Now coming to post-menopause; it is defined as the time after menopause. Natural post‑menopause usually begins in women between their late 40s to early 60s. During post‑menopausal time, many women face bothersome symptoms such as hot flushes, insomnia, mood fluctuations, anxiety and weight gain. Nowadays, varied treatment modalities ranging from acupuncture to hormone replacement therapy are available for post‑menopausal symptoms. However, amongst these, yoga is the most natural treatment option which works wonderfully. It includes breathing techniques, postures, and relaxation poses designed specifically for post‑menopausal symptoms. Improvement in the symptoms such as hot flushes and insomnia has been noted with yoga and meditation [9].

·      Hypothyroidism
Hypothyroidism is a medical term used for underactive thyroid gland wherein your thyroid gland does not make enough thyroid hormone. It most commonly occurs in females than males. The symptoms of hypothyroidism include muscle and joint pain, fatigue, anxiety, sexual dysfunction, dry skin, hair loss, fertility problems, weight gain and poor memory.
Hypothyroidism can be kept under control by taking generic or syntheroid hormone pills once a day. However, yoga and breathing exercises can assist in overcoming thyroid problems along with medications. A study conducted in 2011 to assess the quality of life of female hypothyroid patients, states that yoga is a supportive therapy which helps hypothyroid patients to manage their disease-related symptoms [10]. The yoga poses such as shoulder stand, inverted pose, fish pose, plow pose, cat stretch and fast-paced sun salutation are recommended for hypothyroidism.

·      Psychological impacts in breast cancer patients
According to the National Cancer Institute, more than 230,000 women in the United States are diagnosed with breast cancer every year [11]. Being diagnosed with breast cancer can be most distressing for women. The stress continues even after the treatment as the disease extends over a longer period of time. Yoga and meditation relax the mind and decrease the vulnerability of women with breast cancer. Research has shown that yoga improves physical functioning, reduces fatigue, stress, and improves sleep and quality of life of women [12]. The corpse pose, bridge pose, warrior II pose, crescent lunge pose and hero pose are advised for alleviating breast cancer emotional symptoms.

·      Infertility
Can yoga actually help in treating infertility in women? The answer is yes, it can. Clinical studies show that yoga and meditation reduce stress which is one of the leading causes of infertility. Research has also proven that specific yoga poses and meditation can help promote ovulation process by increasing blood circulation, stimulating hormone-producing glands, and releasing muscle tension. Yoga also tones and nourishes your reproductive organs and encourages them to function optimally. Practicing yoga postures like staff pose, half ankle to knee pose, bridge pose, mountain pose, high lunge with side stretch, Yogini squat, corpse pose and goodness pose can help in curing infertility problems [13].
Thus, yoga and meditation is a holistic approach which improves your body flexibility, strength, posture and strengthen other physical and mental powers. Science has proven yoga to be a promising mind‑body practice which treats various disorders. Therefore practice yoga regularly under trained instructor’s guidance and bring about positive lifestyle changes.

2.     Javnbakht M., Kenari R. H., and Ghasemi M. 2009. Effects of yoga on depression and anxiety of women. Practice. 15(2): 102‑104.
3.     Tacón A. M., McComb J., Caldera Y., and Randolph P. 2003. Mindfulness meditation, anxiety reduction, and heart disease: a pilot study. Family & Community Health. 26(1): 25‑33.
4.     Kristal A. R., Littman A. J., Benitez D., and White E. 2005. Yoga practice is associated with attenuated weight gain in healthy, middle-aged men and women. Alternative Therapies. 11(4): 28‑33.
5.     Lee M., Moon W., and Kim J. 2014. Effect of yoga on pain, brain-derived neurotrophic factor, and serotonin in premenopausal women with chronic low back pain. Evidence-Based Complementary and Alternative Medicine.
6.     Tüzün S., Aktas I., Akarirmak U., Sipahi S., and Tüzün F. 2010. Yoga might be an alternative training for the quality of life and balance in postmenopausal osteoporosis. European Journal of Physical and Rehabilitation Medicine. 46(1): 69­‑72.
7.     Zahra R. 2011. Effect of three yoga poses (cobra, cat and fish poses) in women with primary dysmenorrhea: a randomized clinical trial. Journal of Pediatric and Adolescent Gynecology. 24(4): 192‑196.
8.     Rani K., Tiwari S. C., Singh U., Agrawal G. G., Ghildiyal A., and Srivastava N. 2011. Impact of Yoga Nidra on psychological general wellbeing in patients with menstrual irregularities: A randomized controlled trial. International Journal of Yoga. 4(1): 20‑25.
9.     Booth-LaForce C., Thurston R. C., and Taylor M. R. 2007. A pilot study of a Hatha yoga treatment for menopausal symptoms. Maturitas. 57(3): 286‑295.
10.  Singh P., Singh B., Dave R., and Udainiya R. 2011. The impact of yoga upon female patients suffering from hypothyroidism. Complementary Therapies in Clinical Practice. 17(3): 132‑134.
12.  Cramer H., Lange S., Klose P., Paul A., and Dobos G. 2012. Yoga for breast cancer patients and survivors: a systematic review and meta-analysis. BMC Cancer. 12: 412.