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Journal of Nursing

Yoga and the Benefits to Adults with Chronic Obstructive Pulmonary Disease

Mary Tencza MS RN [email protected]


Background


Chronic Obstructive Pulmonary Disease or COPD is the third leading cause of death in the United States (American Lung Association 2014). Made up of progressive conditions known as emphysema and chronic bronchitis, it is estimated to affect 24 million people with 12 million of those people unaware they have one or both conditions. (COPD Foundation, 2014). According to the National Institute of Health (NIH) (2013) itis estimated that the majority of people are affected with both diseases.

COPD is believed to originate from lung irritants such as tobacco smoke, long term exposure to environmental and workplace fumes and dust such as air pollution and chemicals (NIH, 2013). There is also evidence that it can develop from chronic asthma or a genetic condition known as Alpha-1 Antitrypsin Deficiency (AATD) (COPD
Foundation, 2014). Often first diagnosed when shortness of breath occurs with exertion, the severity of symptoms depends on the degree of damage to the lung tissue (NIH, 2013).

Although there is no cure the National Institute of Health (2013) and the American Lung Association (2014) recommend lifestyle changes such as diet, smoking cessation, and pulmonary rehabilitation. Part of this rehabilitation includes exercises to improve lung function through deep breathing training such as yoga (McCall, 2007).

Current Treatment


With as many as 60% of the home health population afflicted with this disease, finding ways to decrease symptoms and give patients back some type of normalcy in their life is a major goal. Noted by Medicare (2014) “the goal of home health care is to treat an illness or injury…help you get better, regain your independence, and become as selfsufficient as possible” (para 3)

Current pharmacological treatments used for this population are bronchodilators and corticosteroids. As symptoms progress many patients require oxygen use and surgery including lung transplants. Nonpharmacologic methods such as aerobic exercise, stressreduction and cognitive-behavioral techniques are also a consideration. Unfortunately, none of these provide as direct an effect on respiration as deep breathing techniques or pranayama (Gupta, Gupta, Sood and Arkham, 2014). The additional benefits derived from yoga postures such as muscle strengthening and balance provide improvement to quality of life (Fulambarker, Farooki, Kheir, Copur, Srinivasan, and Schultz, 2012).

Yoga


Yoga is touted as a holistic approach to maximize every system in the body through emotional, spiritual, and physical alignment (McCall, 2007).Through exercises such as pranayama (breathing), asana (physical postures) and dhyana (meditation), the calming effects are believed to improve lung function through posture and deep breathing which have been shown to improve pulmonary function capacity and efficiency (McCall, 2007).

This patient controlled approach has a focus on prevention with numerous benefits such as stress reduction, improved immune system response, and psychological equanimity (McCall, 2007). The slower deep breathing of pranayama can improve vital capacity as one learns inhalation and exhalation techniques through the nose. As McCall (2007) notes the benefits of nasal breathing include filtering of pollutants, and reduction in sleep apnea, asthma attacks, and dyspnea. It is also an excellent practice to use when calming or stilling the mind.

Yoga and deep breathing exercises are easy to learn and require minimal time, cost and effort (Gupta, et al, 2014). Hatha yoga which incorporates stretching, balance, meditation, breathing and strengthening exercises are known to be as beneficial as walking or weightlifting (McCall, 2007). With proper teaching on modification the risk
of harm or injury from postures is relatively nonexistent. In fact Donesky-Cuenco, Nguyen, Paul and Carrieri-Kohlman (2009) cited yoga as safe and Gupta, et al (2014) noted pranayama to be “a useful adjuvant treatment as well as rehabilitation measure in COPD patients (p 29).

Research


The goal of yoga is to provide a holistic approach to health maintenance. With a focus on deep breathing and breath control, those that practice yoga report emotional and physical changes as respiratory endurance, mental control, and muscle strength improve (Fulambarker, et al, 2012). As Lin, Yuan, Chien, Weng, Chou, and Kuo (2012) note,
research shows that proper respiratory training or deep breathing (pranayama) has been shown to be an effective exercise to improve pulmonary function and quality of life. As airways are cleared of secretions, inflammation is reduced resulting in increased oxygenation (Gupta, et al, 2014).

Soni, Munich, Singh and Singh’s (2012) randomized control trial (RCT) showed a significant improvement in transfer factor of the lung for carbon monoxide (TLCO), circulation, and oxygen delivery and a decrease in weight and body mass index (BMI) when patients with mild to moderate COPD practiced yoga. A separate RCT conducted
by Donesky-Cuenco, et al (2009) found that yoga improved functional performance and decreased dyspnea-related distress (DD).

When studying the effects of deep breathing techniques or pranayama on stable COPD patients, Fulambarker, et al, (2012) noted that pulmonary function and quality of life significantly improved in their quasi-experimental control design pre and post intervention study. Similar findings were also determined by the RCT conducted by Lin,
et al, (2012). Gupta, et al’s (2014) RCT findings agreed in that pranayama showed significant improvements in quality of life, disease severity and functional status.

Paths to Enlightenment


Bhagavad Gita


Yoga as described in the Bhagavad Gita is a uniting or joining of an individual’s consciousness with an ultimate consciousness (Algeo, 2000). It mentions three yogic paths; karma, bhakti, and jhana (Algeo, 2000). These represent selfless action (karma), devotion (bhakti) and self-transcending knowledge (jhana) (Algeo, 2000). These paths,
practiced individually or combined, will enable one to achieve pure consciousness, devotion, and liberation from bondage.

One who practices karma yoga follows a “path of doing the right thing, of following ones’ personal dharma and accepting destiny as it comes” (Marchand, n.d., para 2). Dharma is noted to be the essential nature of a person. Karma yoga is to act selflessly without harm or thought to one’s gain or selfish expectations. As one seeks to attain
Samdahi or the final limb of yoga the manifestations of support and help toward another will be evident not by word but through action (Algeo, 2000).

The yoga of devotion or bhakti yoga focuses on love for and the relationship with a divine being (Algeo, 2000). Also known as universal love, bhakti yoga leads to “a path of self-realization, to having an experience of oneness with everything” (Isaacs, 2014). It is noted that this path is not the only truth but often believed to be the easiest for most to acknowledge as many hold the belief of a Supreme Being or faith (Algeo, 2000).

Jhana yoga is the path of true knowledge (Algeo, 2000). One on this path aims to attain pure understanding through meditation to realize who we are and what we are experiencing. In seeking the truth one achieves sama or calmness of the mind to renunciate negative thoughts and actions while moving toward atma tattva or soul
realization (Isaacs, 2014).

With the many challenges the COPD patient encounters as their disease progresses, finding peace and freedom through inner contentment will assist them in finding true happiness. “That which is like poison at first but in the end like nectar-that pleasure is declared to be Sattwic, born of the purity of one’s own mind due to self-realization”
(Sivananda, 2000, p 148). Through yoga the mind becomes stilled and finds rest. In this rest one can attain lasting peace and tranquility. This in turn creates a symbiotic effect with the body systems to promote healing.
As pointed out in the Bhagahavad Gita, one should not be afraid to act; being bound by inner limitations and restraints (Algeo, 2000). Even with disease limitations one must not cloud the mind with these colored thoughts but allow them to become uncolored through practice and discipline (Swami Jnaneshvara, n.d.). Learning to follow ones
duties which “arise within ourselves because of who we are” (Algeo, 2000, p 113) through worship, action and knowledge will allow doubts and fears to disappear.

Yoga Sutra


The Yoga Sutras consist of 196 versus that describe the 8 limbed path to completeness and liberation (Doran, n.d., 2013). Each of the limbs builds on the next to achieve Samadhi or perfected concentration. The first two, yama and anyama are the building blocks toward relationships with others and toward oneself (Doran, 2013. As one
practices asana (postures), pranayama (breathing), and pratyahara (control of the senses) an emotional balance is achieved (Swami J, n.d.). The physical body is challenged creating tapas or a sensation of heat through asana and pranayama which is thought of as a purification process (Swami J., n.d.). Pratyahara then severs the senses from external sources and enables the mind to be stilled and focus inward. Doran (2013) notes that
yoga is “a process which enables us to stop and look at the processes of our own minds; only in this way can we understand the nature of happiness and unhappiness, and this transcends them both” (p 8).

Dharana (concentration), dhyana (meditation), and samadhi (deep absorption) are the final 3 limbs to attain a state of total rest where the mind is conscious and alert (Swami J., n.d.). As one concentrates on a single point the mind is wholly engrossed as other thoughts fade away. This concentration is then sustained through meditation as the mind
remains undistracted. This pure consciousness is samadhi (Swami J., n.d.). As noted in the Yoga Sutras, “the ability to allow concentration to go into meditation, and then allow meditation to go into samadhi is a process called samyama” (Swami J., n.d., verse 3.4). At this point the true nature is then revealed as one sees clearly.
“Through the practice of the different limbs, or steps to yoga, whereby impurities are eliminated, where arises an illumination that culminates in discriminative wisdom, or enlightenment” (Swami J., n.d., verse 2:28). Each rung on this path requires patience and practice. Those afflicted with physical constraints often find the mind clouded and
unable to focus on anything else. Practicing asana and pranayama to alleviate and heal physical needs will allow the mind to still and concentrate on inner healing. Doran (2013) makes reference to one of the niyamas; saucha which is purity, a cleansing of the mind and body. “But more important than the physical cleansing of the body is the cleansing of the mind of its disturbing emotions” (Doran, 2013, p 4).

Patients with COPD often find it difficult to perform basic activities of daily living. As one learns inner cleansing this will promote external healing and improve functional performance through balance, strength and flexibility (Doran, 2013).

Mentioned in the Yoga Sutras is the concept of learning a new habit (Swami J, n.d.). Training of the body through asana and pranayama and the mind through pratyahara will “open the physical body to act as a binding agent to bring one in harmony with all the unseen elements of their being, the focus that shape our lives through our responses to the physical world” (Doran, 2013, p 5).

Yoga Practices


The goal of yoga is to provide a holistic approach to health maintenance. With a focus on deep breathing and breath control, those that practice yoga report emotional and physical changes as respiratory endurance, mental control, and muscle strength improve (Fulambarker, et al, 2012). As Lin, et al (2012) note, research shows that proper
respiratory training or deep breathing (pranayama) has been shown to be an effective exercise to improve pulmonary function and quality of life in patients with COPD. As airways are cleared of secretions, inflammation is reduced resulting in increased oxygenation (Gupta, et al 2014).

Fulambarker et al (2012) state in their study breathing techniques of pranayama such as sithali (breathing through a curled tongue), and kapalabhati (rapid force of air from the lungs) were practiced during one hour sessions along with various asana poses of downward dog, child pose, standing forward bend, cat, cow and bridge and meditation
(See Table 1). These postures were modified to meet physical limitations (Fulambarker, et al, 2012). After six weeks of these three times a week sessions COPD patients showed statistically significant improvement in quality of life and pulmonary functions (Fulambarker, et al, 2012).

Another study by Soni, et al (2012) instructed COPD patients in pranayama, asana and meditation for 40 to 50 minutes each day over a two month period. In addition to the breathing exercises used in the Fulambarker, et al (2012) study, bhastrika (bellows breathe) and anulom vilom (alternate nostrils) were used. Asana poses included sun
salutation, mountain, seated forward bend, corpse, and the easy pose (Soni, et al, 2012). Study participants who followed this practice showed a significant decrease in carbon dioxide retention due to the increased intake of oxygen (Soni, et al, 2012). The benefits to the entire body were evident through breath control and relaxation (Soni, et al, 2012).

The positive effects of yoga on individuals with moderate to severe COPD was shown in a study by Gupta, et al (2014). Participants performed pranayama for 30 minutes twice a day over a 3 month period. They were instructed on proper breathing techniques in single nostril, alternate nostril, and bee breath along with kapalbhati (Gupta, et al, 2014). It is of mention to note that bee breath or bhramari is one of the best breathing techniques
to calm the mind (Brahinsky, 2014).

Interestingly, most of the asanas used in these studies have also been noted as most useful to relieve stress and anxiety along with breathing issues (Yoga Journal, 2014). Poses such as the cat and cow elongate the torso and neck, opening the chest cavity to allow lung expansion (Yoga Journal, 2014). Since COPD reduces lung capacity these
poses help to erase or prevent damage from this potentially debilitating condition.

Clinical Implications


Several of this author’s COPD patients have expressed interest in innovative methods to obtain relief from symptoms and allow for better management of activities of daily living. These research studies show that introduction of yoga postures and breathing techniques used conjunctively with prescribed medications can significantly improve one’s quality of life and lessen symptoms (Soni, et al, 2012, Gupta, et al, 2014). This
patient controlled holistic approach has a focus on prevention with numerous benefits such as lung function, stress reduction, improved immune system response, and psychological equanimity (McCall, 2007).

Yoga and deep breathing exercises are easy to learn and require minimal time, cost and effort (Gupta, et al, 2014). However to achieve optimal benefits regular practice is required (Soni, et al, 2012). With proper teaching on modification the risk of harm or injury from postures is relatively nonexistent. In fact Donesky-Cuenco, et al (2009) cited yoga as safe and Gupta, et al (2014) noted pranayama to be “a useful adjuvant treatment
as well as rehabilitation measure in COPD patients (p 29).

Conclusion


Yoga, as noted in the Yoga Sutra, “is the control (nirodhah, regulation, channeling, mastery, integration, coordination, stilling, quieting, setting aside) of the modification (gross and subtle thought patterns) of the mind field” (Swami J, n.d. verse 1:2). This synergistic dance between body, mind and spirit has shown clinically significant benefit to those with life limiting diseases such as COPD. Proper instruction and continued practice in pranayama and asana is noted to offer improvement in quality of life and pulmonary functions.

References


Algeo, J. (2000). The bhagavad gita: A study course. Retrieved from http://www.theosophical.org/files/resources/selfstudy/Gita.pdf

American Lung Association (2014). COPD. Retrieved from http://www.lung.org/lungdisease/copd/

Brahinsky, R. (2014). Buzz away the buzz. Retrieved from http://www.yogajournal.com/practice/2697

COPD Foundation (2014). Are you at risk for COPD? Retrieved from http://www.copdfoundation.org/

Donesky-Cuenco, D., Nguyen, H., Paul, S., and Carrieri-Kohlman (2009). Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: A pilot study. The Journal of Alternative and Complementary Medicine 15(3) pp 225-234. doi:10.1089/acm.2008.0389
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Fulambarker, A., Farooki, B., Kheir, F., Copur, A., Srinivasan, L., and Schultz, S. (2012).

Effects of yoga in chronic obstructive pulmonary disease. American Journal of Therapeutics 19(2) pp 96-100.

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Integrative Medicine 13(1) pp 26-31.

Isaacs. N. (2014). Everyday ecstasy. Yoga Journal. Retrieved from http://www.yogajournal.com/practice/2661/

Lin, W., Yuan, S., Chien, J., Weng, S., Chou, M., and Kuo, H. (2012). The effects of respiratory training for chronic obstructive pulmonary disease patients: A randomized clinical trial. Journal of Clinical Nursing 21(1) pp 2870-2878. doi: 10.1111/j.1365-2702.2012.04124.x

Marchand, P. (n.d.) Karma yoga. Retrieved from http://www.sanatansociety.org/yoga_and_meditation/karma_yoga.htm

McCall, T. (2007). Yoga as medicine: The yogic prescription for health and healing.

New York, NY: Bantam Dell

Medicare.gov (2014). What is home health care? Retrieved from http://www.medicare.gov/what-medicare-covers/home-health-care/home-healthcare-what-is-it-what-to-expect.html

National Institute of Health (2013). What is COPD? National Heart, Lung and Blood Institute. Retrieved from https://www.nhlbi.nih.gov/health/healthtopics/topics/copd/

Soni, R., Munish, K., Singh, K., and Singh, S. (2012). Study of the effect of yoga training on diffusion capacity in chronic obstructive pulmonary disease patients:

A controlled trial. International Journal of Yoga 5(2) pp 123-127. doi: 10.4103/0973-6131.98230

Swami Jnaneshvara (Swami J) (n.d.). Traditional yoga and meditation of the Himalayan masters. Retrieved from http://www.swamij.com/yoga-sutras.htm

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Yoga Journal, 2014. Yoga poses. Retrieved from http://www.yogajournal.com/poses/finder/browse_index

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