Entering medical students at Penn this fall can reduce stress and reinforce their learning through yoga instruction that complements the preclinical medical curriculum.

By Rachel Ewing | Photos by Peggy Peterson

Take a deep breath in. As you breathe out, answer: What did your internal intercostal muscles do when you took that breath?

This isn’t a common question in most yoga classes, but it is part of Yoganatomy at the Perelman School of Medicine, a yoga class that combines traditional yoga practice with reinforcement of lessons in gross anatomy. Yoganatomy is the first part of what will soon be a full suite of yoga instruction designed to complement classes spanning the full three-semester preclinical curriculum.

By mindfully moving and breathing with the body parts that earlier in the day they have learned about in lectures and examined up-close in donated cadavers in the lab, first-year medical students in Yoganatomy gain a deeper appreciation of these structures in a living body.

“The primary goal of Yoganatomy is to give the students an outlet to help them with their stress,” said Nikki Robinson, the yoga instructor who developed and leads these classes. “Here's an hour when they're going to move, breathe, talk about  things we learned in the anatomy lab, and then rest, so they're recharged to go about the rest of their day.”

Robinson said “things we learned in lab” for a reason—and it wasn’t just empathy with her students. Robinson was given permission to attend gross anatomy classes alongside Penn medical students last fall. She was introduced to Penn by Mitchell Lewis, DPhil, a professor of Biochemistry and Biophysics who audited gross anatomy himself some years ago—and still spends a few hours with students in the gross lab each year—out of interest in becoming a better-informed teacher of first-year students. After completing a full gross anatomy course this summer, Robinson is assisting in the lab at Penn this fall. “It is really important for me to be able to accurately reflect and represent what the students were taught,” she said.

Yoganatomy runs in many ways as a typical yoga class, except for the parts that sound more like a gross anatomy study session.

When students are in plank pose—which is essentially holding the “up” position of a push-up—Robinson might say, “Now retract the scapula.” Students are forced to think about the muscles connected to the scapula and to recall the distinction between protraction and retraction.

“I try to straddle keeping it really serious and medically accurate and just giving them something fun to do,” Robinson said.

Medically Informed Yoga

The leader of the next yoga class in the sequence is an inversion of Robinson: Instead of a yoga instructor-turned-part-time-med-school-attendee, Sila Bal is a full-time medical student who became certified as a yoga instructor. Now a fifth-year MD/MPH student at Penn, Bal incorporates her knowledge of anatomy and physiology into teaching yoga.

Soon after she began teaching, Bal got to thinking, “Wouldn’t it have been cool if when I was an MS1 or MS2, someone had gone through what is or isn’t physiologically plausible that’s taught in yoga classes?” Over the course of the last spring semester, Bal developed and taught multiple yoga lessons connected to topics in Mod 2, the preclinical learning block focused on organ systems and disease, and called them Medically Informed Yoga.

“I pick a paper from a reputable journal with trustworthy results and use that as a starting point for our discussions,” Bal said. In connection with the brain and behavior module, she discusses the results of a randomized, controlled pilot study of yoga for depression published by Penn Medicine researchers last fall. The discussion spans the physiology of depression and physiological bases of the use of yoga in depression. “Depression has a lot of research behind it, she said. “For example, we know yoga stimulates the parasympathetic nervous system.”

After a brief discussion, Bal leads the students through a 45-minute sequence of the asanas, or physical postures, that yoga teachers recommend for the organ system under discussion, to practice what they learned.

Creating Connection

The two yoga class sequences—Yoganatomy for first-semester medical students in gross anatomy, and Medically Informed Yoga for second- and third-semester medical students in Mod 2—arose independently by luck or chance last year. This year, the two programs are coming into alignment.

Bal and Robinson are working together to develop a coordinated curriculum of yoga classes to complement the full span of the three semesters of preclinical medical education that can be standardized and repeated in future years.

Already this year, yoga as a study enhancement is front and center for new students. During their orientation in August, new first-year medical students received an introduction to Yoganatomy and Medically Informed Yoga, and participated in a brief demo. Bal, Lewis, and Robinson all believe that all medical students can benefit from yoga through integrating stress relief, exercise, and connection into their often high-stress learning experience.

Attendance was highest last fall at the sessions when Lewis participated, Robinson said. “The students wanted to see their professor’s moves, including an impressive handstand.” The sessions also lured more senior medical students—some of whom said that Robinson’s Yoganatomy quizzes helped them study for board exams—as well as faculty and graduate students from other schools at Penn.

Medically Informed Yoga for Depression

Sudharsan Kriya Yoga is a breath-based meditation consisting of the breathing methods uiiayi and bhastrika, Om chanting, and a form of cyclical breathing called Sudarshan Kriya. It activates vagal afferents, improving autonomic function, neuroendocrine release, emotional processing, and social bonding.

In a randomized, controlled pilot study, led by Anup Sharma, MD, PhDa Neuropsychiatry research fellowin Psychiatry at Penn, researchers found significant improvement in symptoms of depression and anxiety in medicated patients with major depressive disorder who participated in the breathing technique compared to medicated patients who did not partake. After two months, the yoga group cut its mean Hamilton Depression Rating Scale (HDRS) score by several points, while the control group showed no improvements. HDRS is the most widely used clinician-administered depression assessment that scores mood, interest in activities, energy, suicidal thoughts, and feelings of guilt, among other symptoms. 

“With such a large portion of patients who do not fully respond to antidepressants, it’s important we find new avenues that work best for each person to beat their depression,” Sharma said when the study was published in the Journal of Clinical Psychiatry in November 2016. “Here, we have a promising, lower-cost therapy that could potentially serve as an effective, non-drug approach for patients battling this disease.”

Neurophysiology of Sudharsan Kriya Yoga 

Ujjayi: victorious breath

  • Airway resistance à stimulation of somatosensory afferents in pharynx
  • Increased vagal (parasympathetic) tone

Bhastrika: bellows breath

  • Sympathetic activation and CNS excitation on EEG
  • Activation of temporoparietal cortical areas

Om: the infinite

  • Stimulation of Wernicke’s area and the thalamus

Sudarshan Kriya: cyclical breathing with different rhythms

  • Hyperventilation à sensorimotor cortex excitability and thalamic activation

Select Asanas that Benefit Depression

Savasana: Corpse Pose

Surya Namaskar A and B:  Sun Salutations

Salamba Sarvangasana: Shoulder Stand

Paschimottanasana:  Seated Forward Fold

Adapted in part from Medically Informed Yoga materials created by Sila Bal

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