Yoga Therapy for the Heart: Interview with Sonja Rzepski, C-IAYT

Sonja Rzepski is an IAYT-certified yoga therapist and graduate of Prema Yoga Institute’s Yoga Therapy Program. Sonja received her initial yoga teacher certification in the inaugural teacher training of Samahita Centered Yoga Institute in 1999, and originally studied Ashtanga yoga under Eddie Stern. Sonja teaches the Yoga Therapy for Cardiac Care course for PYI; in addition, she was the lead yoga therapist for the Northwell Lenox Hill Cardiac Care Yoga program, whose work was chronicled in a recent study published in the Annals of Clinical Cardiology entitled The Yoga Meditation Heart Connection—A Pilot Study Looking to Improve Women’s Heart Health, which demonstrated a meaningful connection between yoga and meditation practices and improved well-being and decreased depression rates in female cardiac patients, as well as other benefits.

I recently had the opportunity to sit down with Sonja and ask her about her work with cardiac patients as well as about yoga and heart health in general.  What follows are excerpts from that conversation.

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Molly Goforth: Can you talk a bit about how you came to your specialization in cardiac care? 

Sonja Rzepski: It honestly goes way back, because of my mom's experience of having a heart attack, and also my family history of heart disease.  I hadn’t been seeing my parents on a regular basis because I was living in New York City, and they were living upstate when my mother got a job opportunity in the city and I started seeing her regularly.  I noticed that she was looking sort of grey, that she had gained a significant amount of weight, and that she got short of breath easily, just walking down the block. I knew my grandfather had had a heart attack, and that my mother had a significant history of heart disease in her immediate family, as I mentioned.  So I asked her if she had been to the doctor, and she quite casually told me that she had seen her doctor recently and he had said that women couldn’t have heart attacks before menopause.  I asked her if he had done any tests, and she said no. My mother is an extremely upbeat, positive person, but her energy was low, and even though she was having chest pains, her doctor didn’t run any tests and put her on anti-depressants. He just didn’t consider heart disease to be a possibility for a pre-menopausal woman.

MG: I would say that’s unbelievable, but sadly, it’s not.

SR:  No, it’s not.  There is so much information regarding women and cardiac health, and how to prevent heart disease in women.  But regarding my mother, she was told it was indigestion, it was depression, it was anything but her heart.  The only reason she ended up getting an accurate diagnosis is that she happened to go to lecture given by a specialist in heart disease in women at NYU, and she found that she was checking all the boxes, so to speak, regarding her symptoms.  After the lecture she spoke to the doctor, and she ended up becoming a patient, but it took her months to get an appointment. By the time she was finally seen, she actually had a heart attack in the hospital, on the table.

MG: Oh, my God.

SR: She had 92% blockage at that point, and of course the anxiety of it all likely contributed to the cardiac event.

MG: Of course.

SR: Thank goodness she was in the right place.  I was flabbergasted, because it was my own mother and she had been so misdiagnosed for so long.  It became very educational for me; I started to go with her to appointments and I started to become fascinated at the work her doctor, Dr. Steinfeld, was doing.  I wanted to learn more and more, and I started to get more in depth and to apply what I was learning to my yoga teaching.

MG: And how did that progress?

SR: I worked with Dr. Rachel Bond and Dr. DeJesus, and I started working with their support group. They had a women's support group for heart disease and I started basically mentoring with a cardiologist and working with their patients. And thank goodness the doctors were very open-minded and generous.  I mean, I was getting amazing training right there in the hospital. So then it just grew and grew and we started a formal outpatient cardiac class at the hospital.  Our patients had had cardiac events or suffered from heart disease and were seeing the cardiologists, but were not in the hospital at that time. They would return for classes, and that's how this study came about. And then, through Prema, we were able to bring in Yoga Therapy students as mentees, to support the work and even eventually to teach.

MG: What a compelling personal story about how you came to specialize in Cardiac Care. Is you mother doing better now? 

SR: She's doing much better now right. Not only does she lead her own women's support group, she does about 20 to 25 minutes of her own yoga practice every morning.

MG: That’s so great.  Shifting gears a bit, can you speak to working in a hospital setting as a yoga therapist?  What were some of the challenges? 

SR: I think there are actually two great extremes. The cardiologists and the cardiac nurses who saw the results our yoga therapy work was having on their patients were incredibly supportive and bent over backwards to make sure that we had a lovely space to practice in and even supplied water and healthy snacks…they couldn’t have been more supportive. And then the flipside of that is the bureaucracy. Unfortunately, in a hospital setting, even though we're certified yoga therapists, it’s such a new field and with regard to the administration, there's a lot of red tape. When administrative medical professionals don't see the word “licensed” in front of yoga therapy…I’ll just say that there’s still some doubt about the profession, and mistrust, and need for more proof of efficacy. So when studies like ours are done, it’s incredibly important, because anytime you can cite a study it actually brings you that much closer to legitimacy in the eyes of the medical establishment.  Honestly, even to get our study approved took months and months and months, even though we had a bevy of cardiologists supporting it.

MG: That must have been frustrating.

SR: There is a lot of red tape, unfortunately. But our personal experience was always wonderful. Seeing the actual interaction between patients and doctors and nurses and staff on the floor was always fantastic.

MG: Did any of the study’s findings surprise you?

SR: In the upcoming Yoga Therapy for Cardiac Care course at PYI, we will study the Ayurvedic perspective of heart disease and how yoga therapy can address it.  We don’t have the time now to get into a discussion of the complexities of the Ayurvedic concept of doshas and how that relates to cardiac care,  but I can say that the extremely high-functioning, high energy people who would come into the room as patients in our cardiac yoga therapy study…it was often very surprising to me that they were so ready to embrace the practice of yoga and mediation. So one thing that I learned as a yoga therapist working with this population was how important it was to create that safe, sacred space wherever we were.  We would sometimes be in a beautiful room with a fireplace, and other times we would be in the auditorium and they would have to practice… I realized how important was to make the space as consistent and warm as possible, to create that impetus to relax and alter their energy to match the environment.  We tried to incorporate a spiritual element as well, with a singing bowl and playing music before we started, because yes, there was always a lot of energy coming into the room.

I think it was also the weight loss that was actually a surprise to me, as well, because we were doing very, very gentle chair yoga and meditation primarily. But 37.5% of participants lost weight. What the study was really geared toward was dealing with anxiety and depression. And there was a very significant decrease in that, as well. So that was really affirming. It went from a rating of seven to 4.9. 

MG: That's incredible.

SR: Yeah it really is, over a relatively short few months. So that was great. But the weight loss is what really surprised me. And I think part of what made that possible was that the women started to really look forward to coming.  It really became a community, a place where they started to really enjoy talking together and sharing their stories, and the outlook shifted from coming in as a patient and really identifying with their disease to being a part of a support group in a community that was doing healthy, uplifting activity together.  So I really think that we may have had a lot to do with improving other elements of their lives, not simply depression and anxiety but also just their outlook on life: “Hey, I'm going to make more of an effort to get better, because my life matters.”

MG: Speaking of lifestyle changes, are there cultural factors in the U.S. that you feel contribute to heart disease?

SR: Unfortunately, (heart disease) is on the rise and it's the largest killer in the world. And there are quite a few factors cultural factors that contribute. We are becoming less active as a whole. More and more people are waking up, going from their car to work, sitting all day at their job, and going back home and sitting in front of a television. So in general we're becoming less and less active and we don't even realize it. Second, the quality of our food, especially in this country, is just getting worse. There's more and more fast food, but also, even when someone does try to make an effort eat more healthfully, the quality of our meat, the quality of our dairy…and that healthier food is more expensive, all of these factors are truly contributing to declining heart health.

And then there’s a really big one, and it’s stress.  It’s the fact that people are having to work longer and longer hours with worsening health care. And the attendant anxiety this causes, as in,  “Well, I don't want to even go to the doctor because it's going to cost (too much).” There are many contributing factors.

On the bright side, one thing I think is a wonderful value of yoga therapy is that it encourages the client or patient to look at the whole picture of their health, and the more mindful a person becomes, the more they start to care about what they're eating and realize that moving feels good and your life can be strong and healthy. Empowering the agency in their physical form and yet making choices to practice more loving kindness and towards others also highly affects the heart. And this is what I'm very excited about regarding yoga therapy for cardiac care: that we get to bring together all these categories for a healthy life.

MG: Sonja, in your opinion, who is this Yoga For Cardiac Care training for?

SR: First of all, whether you are a personal trainer, a fitness instructor, a yoga teacher or really anyone who is dealing with a population working on their own health, you’re going to obtain such a knowledge base of how not only to recognize the signs and risks of heart disease but also what is effective. Which breathing techniques. Which asana. What languaging is helpful that they can implement and put into their work, whoever they are: acupuncturists, anyone in the wellness field.  And I’d also say that anyone who is supporting a family member or friend with heart disease or anyone who is at risk for heart disease.

MG:
Are there any ways, having worked with women in the study at Lenox Hill, that you think about gender and women when you are thinking about cardiac care in yoga therapy, in addition to how important it is to raise awareness among women about paying attention to their heart health?

SR: You need to have support networks, that is really important to awareness. Because the way heart disease presents in women can be very different from how it presents in men.  So that is number one.
And then I think for women it is really wonderful and important to empower each other. Because very often, for women, it’s easier for them to help a friend rather than to help themselves. So getting them all together allows them to all help one another. And then there is a greater chance that change will happen.

MG: I love that observation: I think that’s a point that should really be amplified. Sonja, I am so looking forward to taking your training, and thank you so much for your time.

SR: You’re very welcome. 

Prema Yoga Institute’s Yoga Therapy For Cardiac Care course, taught by Sonja Rzepski, runs from March 27th-29th at Pure Yoga West. Registration opens February 27th.

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Molly Goforth is a yoga and meditation teacher and a student at Prema Yoga Institute. She specializes in accessibility and trauma-informed yoga teaching and practice.

PYI Yoga Therapy at Mt. Sinai St. Luke's Hospital

Think back: when was the last time you visited the doctor’s office and your primary care physician put on some groovy music and led you and the other patients in a spontaneous dance party?  Never?  Maybe it’s it hard to even imagine your doctor dancing? 

Not so for participants in Prema Yoga Institute’s Yoga Therapy Program at Morningside Clinic, which is run under the auspices of the Institute for Advanced Medicine (IAM) at Mount Sinai St. Luke’s Hospital.  Dr. Vani Gandhi, Infectious Diseases Specialist and Integrative Medicine Specialist and Director of Integrative Medicine at IAM / Mount Sinai St. Luke's and Mount Sinai West Hospitals–while she doesn’t actually dance in the waiting room—frequently attends the yoga therapy classes offered to the clinic’s patient population and starts things off with a energetic, free-flowing chi dance (traditionally employed in such disciplines as Tai Chi, Qi Gong and yoga to stimulate and awaken energy in the body).

Dr. Gandhi’s willingness to participate wholeheartedly in the application of the clinic’s integrative medicine programming is emblematic of IAM’s unique approach to holistic healthcare. In addition to yoga therapy, the Institute also offers massage, acupuncture, meditation and other stress reduction therapies to its patient population as complementary care to traditional medicine, all at no cost to the patient.  Besides primary care services and integrative medicine, IAM also offers HIV primary care, dental treatment, mental health treatment, care coordination to assist patients in obtaining access to care and services, as well as a host of additional programs ranging from transgender medicine and surgery, and support services for patients transitioning out of incarceration.  It is truly a unique public healthcare resource in New York City, and stunningly impressive in its scope.

I recently met with Dr. Gandhi, Susan Mandrew-Jones, the Administrative Manager for The Institute For Advanced Medicine, and Daniele Gates, PYI Yoga Therapist Candidate, E-RYT 500 and yoga therapist in practicum at Morningside Clinic, to find out more about the groundbreaking therapeutic work of IAM in general and the Prema Yoga Institute’s Program specifically.  What follows are excerpts from that conversation.

PYI: How long has the yoga therapy program been in existence?

Dr. Gandhi: There is a very long history of yoga here at the Institute; at least fifteen or sixteen years.   Originally the program provided for a paid position; when the funding for that fell through, I decided to look for volunteer organizations…shortly after that, I was introduced to Dana Slamp, Program Director of PYI, through a doctor who was working at Mount Sinai West, and Dana has continually sent us volunteer teachers.

PYI: Teachers doing their practicum requirement for Prema Yoga Institute’s Yoga Therapy Certification program?

Dr. G.: Yes, Dana sent us Marc Nelles, C-IAYT, who did yoga for the staff, and Angela Rendon, C-IAYT…and after that Susan (Mandrew-Jones) came into the picture and has been instrumental in bringing in consistent volunteers and enlarging the program.  We’ve had a variety of different offerings through our volunteers in the areas of yoga, meditation and mindfulness.

Susan Mandrew-Jones: Dr. Gandhi - in addition to being a primary care provider - also oversees our integrative medicine program. So within that practice we have acupuncture, yoga therapy, massage, frequent workshops: nutrition workshops, actual cooking demonstrations with registered dietitians, so it’s a really wide-ranging program.  We did an herbs and supplements program recently, and our mindfulness and stress reduction program is ongoing.

PYI: And all these offering are under the auspices of the Integrative Medicine Program?

Dr. G.: Yes, most of the offerings are here because this is where I’m based, but all the patients who use the IAM clinics at Mount Sinai Health System as their primary care are able to come here and avail themselves of our programming.

Daniele Gates: I’m curious: How are the programs funded?

Dr. G.:  The two acupuncturists, who work almost full-time—one works four days a week and one works three and a half days a week—they are paid, and the massage therapist who works three days a week is paid.  They are funded by the hospital.  Way back we had some grant funding for these positions, but not currently.  The nutrition program is grant-funded through a Ryan White Food and Nutrition Services grant.  A private donor funds the mindfulness-based stress reduction programming, and that’s been ongoing for four years now.

PYI: Are you aware of another facility in the city that offers this level of integrative care for its primary care recipients?

Dr. G.: No. There are other integrative medicine centers/practices with a variety of offerings, but people have to pay out-of-pocket.  This kind of place doesn’t exist otherwise, as far as I know.

DG: And patients don’t pay, their insurance, if they have it, isn’t charged?

Dr. G: No.

PYI: Is it possible to talk a bit in general about recurring or chronic health issues you tend to see in the patient population who avail themselves of the yoga therapy program?

Dr. G: Our patient population is very diverse; they have a variety of medical conditions, but the ones I see participating are the ones with immune system problems, hypertension, depression, chronic pain: various pain conditions: back pain, nerve pain, headaches, IBS, conditions like that.  Either they ask about it or I refer them, because I have seen (yoga therapy) work well for these specific conditions.  But anyone who is interested is welcome—there are very rare contra-indications for participating in yoga therapy.

PYI: Do you hear any patterns regarding what’s helpful in their yoga therapy work - for example - from patients with HIV or patients recovering from injuries?

SMJ: I can tell there’s increased anxiety when it’s not available!  I think the practice offers the patients what the practice offers all of us.  The feedback… they way they articulate it to us…a sense of calm, and being able to address their life overall.  Someone told me last Thursday, “I feel more organized, I feel like I can set out to do things.”  We talked about being mindful and taking that off the mat.  He stopped in my office again and said, “It’s working.”  And I didn’t ask any more questions, because he looked happy.  The access—because yoga is now seen as this athletic practice—this setting has given them access in that they would never show up at, for example, YogaWorks.  So just being grateful that we’ve made it available and accessible in their bodies, and not addressing their conditions, per se, but supporting their wellness overall, has been what they say about Dr. Gandhi and what they say about the program. “She cares about us.” So it’s created a great sense of community.

PYI: I think that’s a great way of talking about yoga therapy, as not addressing specific conditions necessarily but as supporting wellness in general.

Dr. G.: In terms of specific things that people have said over the years, they say they are able to manage their stress better, they have less pain, they feel they can sleep better, people have said they feel stronger, improved confidence is something which I’ve also heard many times with repeated attendance.

PYI: Have you encountered pre-conceived ideas or trepidation about “yoga” or “meditation” from patients, and if so, how do you address it? 

SMJ: One thing I would credit our patients with is really knowing how take care of themselves and really being partners in their own care with their primary care provider.  So they come with a certain level of information, and based on what they know and what they want to achieve, they come with that curiosity.  They’re very informed: the student who is new and enthusiastic will more likely keep you on your toes than someone who is an experienced yogi.  I would credit our students with having expectations about what they expect to achieve through yoga therapy based on their research and their agency in their own healthcare.

DG: I would say that they’re really great with accepting modifications and not feeling like they’re not “doing it right”. I think that in the beginning students were more hesitant to say “I need to do this differently” and would really try to do it the way that I was teaching it, and I think that, over time, because of the community and because they’ve gotten to know me, they’ve become much more willing to say, “My knee isn’t doing this today, give me another option.”   And I think that’s really great—they’ve really developed a sense of voice and advocating for themselves and what their bodies need.

PYI: Can you speak to how being trauma-informed affects the way you teach the yoga therapy program?

SMJ: I think everything we do in our clinic is trauma-informed.  I think everyone on the staff approaches the patients from that perspective because we know them.

DG: I think the nature of the class, it being in a healthcare setting, necessitates that it’s trauma-informed, so you’re viewing your teaching through that lens from the beginning, more so than you might be in working with clients.  As a Yin teacher, I stick to a very specific number of postures in this class because we can’t use bolsters or blankets, we have to use blocks. So because I want them to feel confident, if I stick to the same postures, they feel like they’re making progress and they don’t feel like they’re thrown into something brand new every class, so in that way it’s trauma-informed.  I also think the language I use—I work really specifically with chakra work every time—I think about teaching the class not as a medical practice but more like teaching to people who have medical symptoms and need an outlet.  It’s not always about teaching yoga “medically,” it’s about dealing with all the ancillary stuff that happens when you have a medical condition of some kind.  That’s kind of the trauma-informed lens that I use: “How can I not be my illness?”  I try to create a room where you’re not your illness.

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I also had the opportunity to speak to two students after observing Daniele’s Yin class at the Morningside Clinic, Douglas and Marquis, who were gracious enough to answer questions about the patient experience of yoga therapy.

PYI: Did you have any preconceived ideas or concerns about practicing asana or meditation before you began the class?  How, if at all, did these ideas or concerns change?

Marquis: The beautiful thing about taking different practices of yoga is that each teacher brings in something that is individualistic or subjective, and so that allows the experience of the practice to be different.  So for me, I get something from Daniele that I don’t get from other teachers, even though I practice yoga regularly.

PYI: You have a regular practice outside of your yoga therapy practice here at the clinic?

M: I do. I do, it’s necessary because I’m overcoming both emotional and physical trauma, and so with that I really have to work very hard to release pent-up energy that is just not circulating in my body, so my body just holds on to tension and stress.

PYI: Is this the only Yin class you take?

M: Yes. Iyengar, which I also take, is definitely a “yang” class! (laughter)

Douglas: I mean, you come to this class trying to figure out, “What is going to make me come back?” and for me, it was the challenge.  I came here and it was like, if I got here, if I just got here, I wasn’t going to leave, I was going to stay and I was going to practice.  You work on things that are helpful, and as you keep working on them…I never did a Yin class, so this was my first time, and also, if I go into yoga classes and they’re too hard—

M: Right.

D: —this had challenges, but it wasn’t so physically challenging that it felt like you didn’t want to come back, you’re going to harm yourself, or it wasn’t accessible to you after, you know: you’re lucky if you got me here.

M: Certainly it’s a nurturing environment.

D: Oh, and the dance part!  Today we had a little intro and that helps gets the body flowing and allows you to open up and accept.  Staying still for a certain periods of time, which is Yin, is very helpful but it’s not as easy as people think.

PYI: Not at all!  Many people consider it one of the most challenging forms of yoga.

D: There is ease in it, but there’s also challenge.  It’s not necessarily strenuous, but for balance for me—I have neuropathy—so for balance positions for me, anything where I have to move around and balance, well, I’m already wobbly. And I’m getting better because of these classes, but that’s an issue for me: too much movement.  It helps to slow it down.

PYI: It’s been said by Dr. Chris Walling that yoga doesn’t heal anything, but that yoga can support the body in healing itself.  Does this resonate with your experience of yoga therapy?

M: I would challenge you on that.  I would say that yoga therapy actually does heal—

D: Me, too.

M: —because it opens up the blockages and allows the healing to take place.  It’s as if you said, “Soap doesn’t clean, but it does allow water to clean, so therefore soap is a cleaning agent.” 

PYI: I see: yoga is so linked to your experience of healing…?

M: Yes. Yoga is a healing agent.

D: Well, actually, for me, for example when we did the exercise today with the abdominals (note: here Douglas is referencing a face-down, supine pose with the low belly supported by a block), I immediately felt it, there was a lot going on that was being released immediately.  It targeted specific issues I was having abdominally.  I think it’s extremely healing.  I’m always the one who wants to feel the effect right away; I don’t want to wait a long time.

PYI: And that pose had that effect for you today.

M: It did.

D: You know, it is one of those things where you will feel the effects right away, but, I think as a guy you might feel that, you know, you’re not working out, you’re not lifting weights, so you’re not doing a whole lot, you’re just doing movement.  But when I leave, the whole realm of my energy is much more controlled, and my ability to just observe and take in information is much more focused.  And so in that, it is a passive reception, and you don’t think that you’re doing a lot, and then two or three days later, you’re body’s like, “Oh!”

M: Also, it’s the simplicity of taking it home with you.  You can do it at home, at your own pace, it’s so simple, and four exercises—I mean, I’ve learned more than four, but there’s four that I do at home in twenty minutes and really feel like I’ve worked on my body: very lightly, very gently, not too much fuss.

PYI: Gentlemen, thank you for sharing your thoughts, it’s been very enlightening.

D: You’re welcome.

M: You’re very welcome.  You’re welcome back any time!

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The time I spent with the Mt. Sinai team and students illuminated and expanded my understanding of the practical role of yoga therapy in healthcare and its efficacy in the support of primary care.  I am indebted to Dr. Gandhi, Susan Mandrew-Jones, Daniele Gates and the patients at the Institute for Advanced Medicine for allowing me to observe and investigate their process.  Further information about Prema Yoga Institute’s Yoga Therapy Certification Program—which includes a practicum such as the one Daniele is completing at Morningside Clinic, can be found here.

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Molly Goforth is a yoga and meditation teacher and a student at Prema Yoga Institute. She specializes in accessibility and trauma-informed yoga teaching and practice.

Medical Journal Publishes PYI-Led Pilot Study on Yoga for Cardiac Health

Really good tidings! Motivated by her mother’s own cardiac event, Prema Yoga Institute alumna and faculty member Sonja Rzepski created a yoga therapy program alongside doctors at New York’s Lenox Hill Hospital to help manage stress in female patients recovering from similar experiences. The cardiac care program was part of PYI's Clinical Yoga Therapy Practicum, and was staffed by PYI grads completing their yoga therapy certification.

The results are in and not only are they are encouraging but they are now published in the Annals of Clinical Cardiology (Jesus SD, Schultz E, Bond RM. The yoga–meditation heart connection: A pilot study looking to improve women's heart health. Ann Clin Cardiol 2019;1:24-9). 

While on the decline overall, the CDC still declares heart disease the leading cause of death for women in the United States. For women older than 55, the data shows a stagnation in the decrease of fatal incidents. Stress, anxiety, and depression are nontraditional risk factors for cardiovascular disease (CVD) that are more common in women. Sonja’s hypothesis appears to be supported by evidence that regular, supervised sessions of chair yoga and meditation can be a complementary measure to decrease these factors in female patients with or at risk for CVD, as well as increase their likelihood to pursue lifestyle modifications. 
 
Sonja’s program addressed this specific group by providing 16 female participants with or at risk for CVD and with a mean age of 64, 45-minute supervised sessions of complimentary chair yoga and meditation over 24 weeks. Through the practice of Yoga Nidra, psychic sleep or deep relaxation with inner awareness, the patients reported a lower level of depression overall as well as a 3-9 pound weight loss in 1/3 of the students which reflects the program’s encouragement to mindfully eat heart-healthy foods.
 
Kudos to Sonja and her team that included PYI Practicum students Yuliana Kim Grant, Irina Chernova, Judy Glassman, and Michelle Lauren. Want to dig in and read the complete study?  Click here! 

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