Sharma ijyt2008 digitalupload

SYTAR 2008Saturday 03/08, 2008 (Track 2.01)

Yoga for Respiratory Challenges

Vijai Sharma, PhD, RYT

Program Description

Information about respiratory challenges(Restrictive and obstructive breathing) for yoga practitioners Provides yoga tools and solutions for respiratory challenges Evidence for benefits of yoga asanas and pranayama techniques for lungs and breathing

Biodata

1994: Diagnosed with Emphysema

2007: Completed Quad Bypass with honors

Intention of the Presentation

Informed thinking about a person with respiratory challenges

Tools and Solutions for Challenged breathing

Informed thinking about a person with respiratory challenges

Why Should We Do It?

“Breath is central to yoga because it is central to life”

T. Krishnamacharya

Because…………………..

“When you can’t breathe nothing else matters”

American Lung Association

What Is it Like?

A “straw” and a “squeeze” are worth a thousand words

What it’s like to breathe? (2)

Take a deep breath (dirgh shvasa)

Don’t let it out

Now, try to take another breath

Major Respiratory Challenges

“Restrictive Breathing” (e.g. PF/or asthma in parts) mainly the problem of getting the air IN

“Obstructive Breathing” (Emphysema/ COPD) mainly the problem of getting the air OUT

Adult Asthma and COPD

Adults with asthma were at 12 times higher risk of acquiring COPD than those without asthma

In a longitudinal study 1 in 5 people with asthma developed functional signs of COPD

Results from the Tucson Epidemiological Study of Airway Obstructive Disease and a longitudinal study cited from GOLD 2006, p.31)

Several yoga studies suggest slow breathing

can help

Yoga can help with structural problems

e.g. scoliosis to facilitate breathing

Emotional management and

calming with yoga

Activity planning and

pacing

Avoid allergens, pollution and

smoking

Comments on restrictive breathing

Focus: Chronic Obstructive Pulmonary Disease (COPD)

Shortness of breath (progressive, everyday, worse with exertion, “air hunger”/discomfort)

Chronic cough

Chronic excessive mucus (> McDonald ketch-up bowl a day)

Mild SOB is often explained away

I am getting

I have put on so much

I am out of

Because “I smoke/d”

Moderate SOB

Avoid activities that leave one out of breath

Find “shortcuts.”

*If no troubling symptoms, no medical consult

Severe SOB

Symptoms more than a “nuisance”

Daily activities significantly affected

Typically, doctor is consulted at this point

Some May be “walking” with You

“Millions of airways…provide so much reserve that most people may not notice it if they lost the use of a third or even half of a lung”

– From the smoking Boom Comes a Major killer of women: New York Times, National Thursday, Nov. 29, 2007

Wide-spread “breath illiteracy”

The Hydra Headed COPD

Multiple co-morbid disorders e.g. Heart Disease, Osteoporosis, GERD, Depression, Anxiety etc.

Yoga with its wide-ranging effects on body, breath and mind must be explored

Medical Source Documents

GOLD (Global Initiative for Chronic Obstructive Disease)2006

GINA (Gobal Initiative for Asthma) 2006

ATS-ERS Pulmonary Rehab Statement 2005

Slightly paraphrased for yoga context

During Exercise/Exertion

Getting the air out of lungs becomes ever more challenging More CO2 builds upWanting to breathe more and faster (air hunger) Lungs over inflate (Dynamic hyperinflation) Leaving less room in the lungs for fresh air to get in

“Vicious cycle” sets in during exercise/exertion

>Work of breathing increases

>Breathing discomfort (Dyspnea)

>Breath anxiety and activity avoidance

<Fitness level

“Virtuous Cycle” with Breath Awareness

Timely breath regulation

Activity modulation and breath pacing

Reduced Dyspnea episodes

Reduced breath anxiety, more yoga, more exercise/activity

“They” and “Us” Want the Same things 1

>Oxygen

>Blood flow in the skeletal muscles

>Personal/household activity level

<Shortness of breath

*Some evidence for exercise training benefits in these areas

“They” and “Us” Want the Same things 2

Improve cardiovascular function

Improve emptying out of lungs

Reduce mood disturbance

Develop stress management skills

*Some evidence that exercise training provides benefits in these areas

Relaxation Training

“Relaxation training should be incorporated in the patient’s daily routine…(which) can be accomplished through techniques such as muscle relaxation, imagery, or yoga.”

(*Yoga has all those things!)

Stress Management

“Patient should be …capable of stress management techniques”

(*Yoga increasingly being recognized for stress management)

Tools and Solutions for Challenged Breathing

Evidence based strategies 1

Strength training may increase muscle mass and reduce dyspnea during exercise

Shorter sessions w/pause may help progress to a more intensive level

Combination of strength and endurance training is “best strategy”


Session ideally 30 minutes or more

Three sessions a week of which at least two should be supervised

Minimum of 20 sessions

Evidence-based strategies 3

“Both upper and lower extremities (during exercises) should be utilized”


“Walking, bicycling, treadmill for endurance training”

(Variety of activity & exercises are needed--Sharma)

*

Yoga Strategy —First Things First

Body, breath and mind relaxation with Shavasana adaptations

Lengthening the exhalation

Slowing the breathing

24-7 Breath awareness and monitoring

Control over dyspnea

Breath coordinated stretches

Pacing of activity with breathing

Yoga Strategy-

Asana that don’t excessively strain the breathing

Help excrete the sputum

Increase the elastic recoil of the lungs

Yoga Strategy- A session should include

Asanas to exercise the whole body (arms, legs and trunk); chair for those who need itMove the spine in every which way (forward, back, lateral, twist, vertical) underutilized in rehab programsCoordinate spinal and other movements with adaptive breathing (underutilized in rehab programs)

Yoga Strategy- Restorative and Relaxing Asana

Nourishment for overworked heart and lungs

Economy of effort for maximum benefits

Facilitate strengthening exercises

Progress from “passive” asanas to more “active” as the condition improves

Yoga Strategy- Consider Props and other Supports

Increase of blood flow for longer duration to various muscles and organs

Rest the heart and lungs

Relieve fatigue

*Caution: Some props are effort- intensive and unaffordable for home use

Asana effects from pulmonary perspective

Source Documents

Bio-Mechanics of Yoga by Dr. Krishna Raman

http://www.medicineau.net.au/columns/yoga/biomech.htm

Yogic Management of Pulmonary Diseases

(Chronic Bronchitis and Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp

Forward bending

Allows lungs and heart to rest

Stretches the posterior part of the lungs

Relieves fatigue

*Caution: breathing in Child Pose or chair Uttanasana may be difficult for some

Pulmonary Medicine on Forward Bending

“Forward leaning has been noted clinically to be effective in COPD and is probably the most adopted body position. …..(forward) leaning with arm support, decreases dyspnea, and increases exercise capacity”

Am J Respir Crit Care Med Vol 173. pp 1390–1413, 2006

p.1398

Backward Bending

“Heart is stretched out along with the left ventricle as can be seen on the echocardiogram”

Cardiac muscle is also toned up by molding the supporting structures of the heart (dorsal spine)

Angina lets up “Clear the bronchial tree of mucus” Opens the thoracic cage and create negative

pressure in the lungs Allows blood from the right ventricle to enter

without strain

Lateral Stretch Standing poses(e.g. Triangle & Revolving Triangle)

Expand the intercostals Tone up the lung walls Stretch the lungs

* Utilize chair or wall support when indicated

Twisting Poses(standing, seated or reclining)

Increase the elasticity of intercostals

Squeeze and stretch the lungs

Squeeze the lateral parts of the lungs

Standing Poses

Leg fatigue a common complaint in COPD

*Standing yoga poses can be helpful but you need to build up the strength gradually

Supine Poses (viz. Supta Virasana, Baddha Konasana with pillows)

“Deep breathing done in these poses ventilates the lungs”

Rests heart and lungs

Relieves fatigue

Bio-Mechanics of Yoga by Dr. Krishna Raman http://www.medicineau.net.au/columns/yoga/biomech.htm

Supta Virasana and Viprita Karni

“Supta Virasana and Viprita Karni are very useful to remove strain on the heart and reduce the respiratory rate in the emphysematics”

Yogic Management of Pulmonary Diseases (Chronic

Bronchitis and Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp

* adaptations may be required

Inversions (e.g. Supported Viprit Karni, Dwiparda pitham)

“10 % increase in the ejection fraction (heart pump) in Setubandha Sarvangasana”“Ultrasound shows that Urdhava Mukha Svanasana improves the flow of blood into the ascending aorta (heart)”

Bio-Mechanics of Yoga by Dr. Krishna Raman http://www.medicineau.net.au/columns/yoga/biomech.htm

Help drainage from the basal parts of the lungs

Yogic Management of Pulmonary Diseases (Chronic Bronchitis and Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp

Pranayama-

“Improves mucocilliary clearance and stamina”

Yogic Management of Pulmonary Diseases (Chronic Bronchitis and

Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp

First Dyspnea control, relaxed breathing breath awareness and breath control

Pranayama-

“The practice of Kumbhaka (breath retention) facilitates better percolation of oxygen into the lungs”


Pranayama

“(Lying down on a prop), the strain on the accessory muscles of respiration reduces and he or she can make a `relaxed effort' to empty the lungs.”“The dorsal spine must be supported by a prop. Only then must breathing begin.”


Utilize: Longer and slow exhalation to empty the lungsCoordinated emptying and filling of the lungs lying down, seated, supportedGentle asana coordinated breathing

Cleansing of the respiratory system

Gentle alternate nostril bhastrika

Gentle, slow Kapalabhati

Gentle, slow anuloma-viloma (alternate nostril breathing)

Purrsed Lip Breathing (PLB)-1

PLB compared to spontaneous breathing:

Prolongs active expiration

Helps to prevent airway collapse.

Reduces respiratory rate, dyspnea, and CO2 level

Improves tidal volume and oxygen saturation in resting conditions”

Am J Respir Crit Care Med Vol 173. pp 1390–1413, 2006 p.1398

PLB-2

“…many patients with chronic lung disease use this technique (PLB) instinctively and report decreased dyspnea with its use.”

Am J Respir Crit Care Med Vol 173. pp 1390–1413, 2006 p.1398

Let’s practice P.L.B?

It’s not Shitali or Ujjayi (try them later)Purse your lipsExhale slowly and evenlyMaintain consistent outflow

Later, “OOOOmmm PLB”

Caution on D.B. Training

“To date, evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD”

Am J Respir Crit Care Med Vol 173. pp 1390–

1413, 2006 p.1398

How ATS/ERS define DB?

“Diaphragmatic breathing techniques require the patient to move the abdominal wall out during inspiration and to reduce upper rib cage motion”

– Am J Respir Crit Care Med Vol 173. pp 1390–1413, 2006 p.1398

*Instead of claiming DB we should target relaxing neck & shoulder muscles while breathing

Add to the Yoga Practice

Aerobics: e.g. walking, treadmill, elliptical, etc.

Resistance: e.g. light weights

Support group: Local/Online

What to expect with Yoga

Breathing Techniques

Dyspnea/ SOB Control

Whole Body Fitness

Relaxation Skills

Stress management Skills

Mental/ emotional

perspective

The Future Winner

After supervised 20/30 sessions, a home-based graduated program that evidences long-term adherence, safety, benefits, wider acceptance and reduced medical cost

Who are the people who adhere and benefit significantly from such a program?

Contact Namaste

[email protected]

www.mindpub.com/copdhome.htm