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

1. SYTAR 2008Saturday 03/08, 2008 (Track 2.01) Yoga for Respiratory Challenges Vijai Sharma, PhD, RYT

2. 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

3. Biodata 1994: Diagnosed with Emphysema 2007: Completed Quad Bypass with honors

4. Intention of the Presentation Informed thinking about a person with respiratory challenges Tools and Solutions for Challenged breathing

5. Informed thinking about a person with respiratory challenges

6. Why Should We Do It? “Breath is central to yoga because it is central to life” T. Krishnamacharya

7. Because………………….. “When you can’t breathe nothing else matters” American Lung Association

8. What Is it Like? • A “straw” and a “squeeze” are worth a thousand words

9. What it’s like to breathe? (2) • Take a deep breath (dirgh shvasa) • Don’t let it out • Now, try to take another breath

10. 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

11. 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)

12. Comments on restrictive breathing Several yoga studies suggest slow breathing can help Activity planning and pacing Avoid allergens, pollution and smoking Emotional management and calming with yoga Yoga can help with structural problems e.g. scoliosis to facilitate breathing

13. 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)

14. Mild SOB is often explained away • I am getting • I have put on so much • I am out of • Because “I smoke/d” OLD WEIGHT SHAPE

15. Moderate SOB Avoid activities that leave one out of breath Find “shortcuts.” *If no troubling symptoms, no medical consult

16. Severe SOB Symptoms more than a “nuisance” Daily activities significantly affected Typically, doctor is consulted at this point

17. 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

18. Wide-spread “breath illiteracy”

19. 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

20. 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

21. During Exercise/Exertion • Getting the air out of lungs becomes ever more challenging • More CO2 builds up • Wanting to breathe more and faster (air hunger) • Lungs over inflate (Dynamic hyperinflation) • Leaving less room in the lungs for fresh air to get in

22. “Vicious cycle” sets in during exercise/exertion • >Work of breathing increases • >Breathing discomfort (Dyspnea) • >Breath anxiety and activity avoidance • <Fitness level

23. “Virtuous Cycle” with Breath Awareness • Timely breath regulation • Activity modulation and breath pacing • Reduced Dyspnea episodes • Reduced breath anxiety, more yoga, more exercise/activity

24. “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

25. “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

26. 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!)

27. Stress Management “Patient should be …capable of stress management techniques” (*Yoga increasingly being recognized for stress management)

28. Tools and Solutions for Challenged Breathing

29. 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”

30. Evidence based strategies 2 • Session ideally 30 minutes or more • Three sessions a week of which at least two should be supervised • Minimum of 20 sessions

31. Evidence-based strategies 3 “Both upper and lower extremities (during exercises) should be utilized”

32. Evidence based strategies 4 “Walking, bicycling, treadmill for endurance training” (Variety of activity & exercises are needed--Sharma) • *

33. 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

34. Yoga Strategy- • Asana that don’t excessively strain the breathing • Help excrete the sputum • Increase the elastic recoil of the lungs

35. Yoga Strategy- A session should include • Asanas to exercise the whole body (arms, legs and trunk); chair for those who need it • Move the spine in every which way (forward, back, lateral, twist, vertical) underutilized in rehab programs • Coordinate spinal and other movements with adaptive breathing (underutilized in rehab programs)

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. Twisting Poses(standing, seated or reclining) Increase the elasticity of intercostals Squeeze and stretch the lungs Squeeze the lateral parts of the lungs

44. Standing Poses Leg fatigue a common complaint in COPD *Standing yoga poses can be helpful but you need to build up the strength gradually

45. 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

46. 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

47. 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

48. 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

49. Pranayama- • “The practice of Kumbhaka (breath retention) facilitates better percolation of oxygen into the lungs” Yogic Management of Pulmonary Diseases (Chronic Bronchitis and Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp

50. 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.” Yogic Management of Pulmonary Diseases (Chronic Bronchitis and Emphysema) http://www.webhealthcentre.com/altmed/yoga/yg_tool.asp Utilize: • Longer and slow exhalation to empty the lungs • Coordinated emptying and filling of the lungs lying down, seated, supported • Gentle asana coordinated breathing