Yoga-Based Program for Emphysema/COPD

Stretching and Breathing Suggestions for Maintenance of Lung Function

Vijai P. Sharma, Ph.D

Introduction

This document was developed by an interdisciplinary team of people with COPD, yoga teachers, health care professionals (pulmonary physicians, respiratory therapists, physical therapists and nurses with respiratory focus) and self-care advocates. We have tried to understand and define optimal techniques and methods from both current knowledge of anatomy and physiology and yoga perspective. These methods may be used individually or as complementary activities.

Most people with COPD deal with breathing discomfort on a daily basis and they want to gain control over their breathing. Once they discover that by purposefully manipulating their breath, they can reduce their breathing discomfort, they might feel even more motivated to participate in social and recreational activities leading to a better quality of life.

Our primary purpose is to give people with COPD some basic principles and techniques for incorporating optimal breathing for exercise and activities of daily living. Relieving shortness of breath should improve their ability to function more comfortably.

Because each person is unique in his/her medical condition and personal circumstances, the information needs to be individualized. Much of this process requires you, the person with COPD, to interact and work out which techniques seem best for you. As with any new exercise or activity, evaluating which techniques are appropriate for a given person may require professional help. Consult a medical professional if you have concerns or experience an unusual increase in shortness of breath or discomfort with any activity.

If you are a health professional, yoga teacher, or exercise and fitness instructor, you may wish to consider incorporating these ideas into your own practice framework and approach, to meet the specific and individualized needs, medical condition and circumstances of the person with whom you are working.

We encourage individuals and medical and rehabilitation programs to conduct scientific investigations in order to study the outcomes of the ideas presented in this model. When people with COPD add to their regular medical treatment such self-care tools as breath regulation skill, breath training, and stretching and exercising in coordination with breathing, they may be able to exercise greater control over their breathing, ameliorate their breathing discomfort and improve their daily function.

*The self-care model was composed by Vijai Sharma, PhD in consultation with a multidisciplinary "Breathing Team" consisting of COPD patients and patient advocates, chest physician, physical therapists, respiratory therapist, yoga instructor and nurse specialist with pulmonary specialty.

Outline

Master the Breath Regulation Skill
1. Breath Management and Dyspnea Control Strategies
2. Relaxation Strategies
3. Exertion Strategies
4. Stress Management Strategies
Breath Training
Step-By-Step Breath Training Program
Other Breathing Training Aids
Breath and Movement Coordination
General Guidelines
The Five spinal movements
Spinal direction and breath coordination
Adopt a Comprehensive Program
Whole-body strengthening and flexibility
Other activities and exercises

Master the Breath Regulation Skill

Mastering "breath regulation skill" involves identifying YOUR best breathing patterns including the optimal breathing rate and length of inhalation and exhalation for the following: 1) Dyspnea (breathing discomfort, shortness of breath or other breathing difficulties and irregularities) 2) Normal resting condition and relaxation 3) Exertion (exercise, stretching, walking, etc.) and performance of activities of daily living, and 4) Emotional stress and excitement.

Following strategies may help you to work towards these goals: 1) Breath Management and Dyspnea Control Strategies 2) Relaxation Strategies 3) Exertion Strategies 4) Stress Management Strategies

1. Breath Management and Dyspnea Control Strategies

The term "Dyspnea" refers to breathing discomfort, shortness of breath or other breathing difficulties and irregularities. By practicing "24-7 proactive breath management" Dyspnea episodes can be eliminated or at least reduced in intensity.

Breath management requires continuous breath awareness, close monitoring and prompt correction of any irregularity noticed in the breathing pattern. When you notice breathing problems, stay calm, relax and try to breathe slowly. There are some breathing strategies to steady the breath that you can learn and apply. As a result, you can minimize breathing problems at least some of the time.

Sometimes, dyspnea can occur suddenly, but other times it gradually builds up to the point of aggravation. A dyspnea episode may begin as a minor change in the rate and depth of breathing or stem from some other irregularity in breathing. It can grow to a significant extent outside your awareness. You only notice it when you feel extremely short of breath or experience significant discomfort.

It is important to recognize that at least some episodes of dyspnea occur as a result of incorrect breathing such as "reverse" breathing, that is, abdomen going IN rather than OUT during inhalation. When you correct the reverse breathing pattern, you may experience significant relief. By maintaining constant breath awareness, you can detect breathing problems/changes early enough and correct them right away, thus preventing or at least modify a Dyspnea episode.

For breath management and development of Dyspnea control strategy, prepare specific interventions for the following problems or symptoms, if applicable:
" Shortness of breath
" Hyperventilation (or, "Over Breathing")
" Upper chest, neck and shoulders breathing
" Hyperinflation and Dynamic Hyperinflation
" Hypoventilation (or, "Under Breathing")
" Remove Obstacles to your Optimal Breathing

Shortness of Breath

When you experience shortness of breath, restore normal breathing by such means as telling yourself to relax and doing "Pursed Lip Breathing (PLB)." You may silently count (e.g. 1-2-3-4) while inhaling and exhaling. Counting along with PLB can help to slow down breathing. Exhale a count or two longer than what you count on inhale. Exhaling efficiently will help to empty the lungs of excess stale air and make room for fresh oxygen.

"Hyperventilation" or "Over breathing"

You may hear terms such as "Hyperventilation," which literally means taking in more air. I refer to it as "Over breathing," which conveys that you are taking too many breaths. For example, normal rate of breathing for people who have healthy lungs is 12 to 15 minutes a breath. When someone takes significantly more breaths than the normal rate, we would say, "He (or she) is hyperventilating." Your subjective experience of this might be something to the effect, "I can't catch my breath." In essence it is same old "shortness of breath." You begin to feel uncomfortable when breathing accelerates. As a result you breathe more rapidly. This is what some people describe in words to the effect, "I started huffing and puffing and I could do nothing to stop it."

If you feel you are breathing more rapidly than your usual, slow the breathing down even though you might feel the need to breathe faster.

Upper chest, neck and shoulders breathing:

The moment you notice even the slightest increase in the following: chest breathing, recruitment of neck and shoulder muscles during inhalation, slowly, steadily and consistently start doing Pursed Lip Breathing (PLB). At the same time start relaxing your entire body. Relax your shoulders. Gently allow the shoulders to move towards back and down. Feel the shoulders blades sliding down. Allow the breath to move down to lower chest. If you have learned diaphragmatic breathing, restore diaphragmatic breathing.

"Hyperinflation" of the lungs and Dynamic Hyperinflation

You may also hear the terms as "Hyperinflation" of the lungs (or briefly referred as HYP) and Dynamic Hyperinflation (or briefly referred as DH). It is very important to know about hyperinflation of lungs.

The word, "Emphysema" is derived from "emphysan," which means "to inflate" or "blow in." Therefore "Emphysema" literally means inflated or enlarged lungs. Emphysema is included under the umbrella term "Chronic Obstructive Pulmonary Disease (COPD)." The obstructive condition does not allow you to take all the air OUT that you get IN, inside your lungs. Lungs are like balloons. If you keep putting in more air in the balloon than you take out, the balloon will inflate. Talking specifically about the lungs, the excess air will be trapped in the air sacs (alveoli). Alveoli are like bunches of miniscule grapes attached to a branch (also called "air tubes" or small airways). The trapping of air in the alveoli which results in over inflation or enlargement of lungs is called, "Hyperinflation of lungs (or HYP)."

Dynamic hyperinflation (or DH) means that there is already hyperinflation of lungs and the individual REACTS to it and further hyper inflates the lungs. Dynamic hyperinflation results from breathing more rapidly (and shallowly) in trying to get the air in because one feels, "I can't get the air in" or "I can't catch my breath."

It feels counterintuitive to lengthen your exhalation when you so desperately want to inhale more and more air. But gradually and slowly lengthen your exhalation, you must. You have to create more room in your lungs to fresh air to get in. Your best bet is to slowly, steadily and consistently do Pursed Lip Breathing (PLB) to get the excess air out. This will help to breathe better and reduce the amount of excess air accumulated in the lungs. Thus, you may be able to stop the process of further over inflation of lungs, called "hyperinflation of lungs."

For fuller explanation and related information on hyperinflation and dynamic hyperinflation, visit the website of chest physician Deane Hillsman, MD. He has written it in the style of a "doctor-patient" dialogue. http://www.sierrabiotech.com/bt_copd_home.htm

Hypoventilation (Under breathing")

Hypoventilation or "under breathing" refers to breathing less than your usual. In under breathing, it is like your diaphragm doesn't want to move and lungs don't want to breathe. During under breathing, you might be taking too long a pause between the breaths. Recognize under breathing immediately. Gently stretch your body particularly your spine, engage your breathing muscles and progressively work up to a normal rate of breathing.

Normalize your breathing whenever you start over breathing or under breathing. Gradually and steadily bring it to the rate and length of breathing that is normal for you.

Remove Obstacles to Your Breathing: Optimize Your Breathing

You may have to make further accommodations when symptoms are exacerbated or your stamina is unusually compromised. Consult a professional and experiment until you can determine your best breathing patterns. Once you have learned which particular breathing pattern works best for a given situation, apply them consistently and appropriately until those breathing patterns become such a habit that you can do them naturally and automatically.

Do gentle, slow and deep breathing as much as possible. Avoid shallow breathing or "panting breath." Gentle and slow breathing facilitates gas exchanges at optimal levels. Research shows six breaths a minute (total duration of inhalation and exhalation=10 seconds) improves the efficiency of gas exchange in people without known pathology or impairments, and improves 6-minute walk distance in people with COPD.

Form the habit of exhaling longer than inhaling, and often substantially longer than inhaling. For example, if you take a 10-second breath (6 breaths per minute), ideally, you may inhale for a count of 4 and exhale for a count of 6.

Perform breathing exercises daily just as you perform other exercises for toning up your muscles. Regularly practice slow and deep breathing. Gradually and steadily increase the length of your inhalation and exhalation.

2. Relaxation Strategies

Regular practice of mental and physical relaxation may help you to breathe more easily and relieve some types of breathing discomforts. Relaxation is a skill and can be learned. If you find it hard to relax, learn "how to." There are tapes and books on how to relax which guide you in relaxing the major muscle groups from head to toe including arms and hands. In order to relax mentally, you picture a beautiful, peaceful and relaxing place. You may silently repeat a calming word such as "relax" or "calm."

Whenever possible, relax your body, relax your breathing and relax your mind! Take a few minutes as often you can and just do relaxed breathing. Relaxed breathing is smooth, rhythmic and consistent flow of breath. Inhale and exhale slowly and gently. Regular practice of relaxed breathing over time can help towards regulating your breath.

Do mini-relaxation sessions, 5 minutes each time, three or four times a day. Do one 15 to 20-minute relaxation session in which you physically and mentally relax for 10-15 minutes and then do 5-10 minutes of smooth, relaxed, slow and deep breathing. Try to relax physically and mentally when resting. Proper and adequate amount of rest and relaxation may show improvement in daily function and exercise.

3. Exertion Strategies

They say, "Don't work harder, work smarter." We say, "Whenever exert, exert smarter."

While performing an activity, exercising, walking or engaging in any other type of exertion and effort, modulate your level of effort and speed so you can breathe within your optimal breathing zone. Breathe efficiently by learning to pace your breath and whenever needed adjust the level of exertion and speed. Maintain the rate of breathing and the length and volume of the breath that is most suitable for you. Working too hard or too fast can cause shortness of breath or some other breathing discomfort, but working well below your capacity wouldn't give you a satisfactory work out. Figure out your optimal range.

Remember, "Slow and steady wins the race!" By regulating your breath, gradually increasing your effort and speed, and staying within your range, you might be able to do more and do it for a longer time. Constantly monitor your breathing. Whenever indicated, slow down and pace your breathing in order to avoid breathlessness. With any exertion, always remember to concentrate on breathing out so lungs don't accumulate excess air.

4. Stress Management Strategies

Breath regulation also requires emotional regulation and stress management. Stress, anxiety, panic, depression, anger or any type of excitement, can disturb your breathing. When you find yourself in such negative emotional states, try to neutralize your emotions. Quickly calm yourself and restore your breathing to your normal, which would also result in further reduction of the negative emotional state. Negative emotions and excitement disturb our breathing. Slow and deep breathing can help to neutralize the disturbed emotional state. Replace negative thoughts that might be fueling the negative emotions.

People with COPD often experience significant anxiety related to their breathing. Some don't want to focus on breathing unless they are forced to by increasing breathing discomfort. By losing anxiety/tension related to breathing, you can be more relaxed. Paying attention to breathing in the beginning might make you anxious, but it will go away with practice. Pay relaxed attention to your breathing. Make it a habit to relax each time you breathe out.

Summary of Breath Management Strategies

Adopt this slogan as your own, "Breath monitoring and breath management all the time." Let this be a "24-7 proactive breath management." Pay relaxed attention to your breathing. The moment you notice even a slight unwelcome change in your breathing, start regulating it gradually and steadily. Constant awareness of breathing will help you to promptly adjust and adapt to the demands of different situations.

Breath Training

If you are a person with COPD or a person with healthy lungs, training the breath is beneficial for everyone.

A major component of breath training is to keep the movement of breath in the lower chest and the abdomen all the time until you want to manipulate your breath for some other specific purpose.

Breath training involves manipulating your breath at will such as relaxing, slowing and deepening your breathing. Breath training can also include diaphragmatic breathing. Once you get the diaphragmatic breathing down pat, some of you may be ready and willing for advance breath training.

In the advance breath training, you learn to correctly and systematically engage the pelvic floor, the pelvis, abdomen, mid-section and the upper chest area, taking a "full breath." In other words, when you take full breath, you engage the perineum to thorax during breathing while keeping the neck and shoulders relaxed.

Step-By-Step Breath Training Program
1. Drop the neck and collarbone breathing. Learn to relax and disengage the already tightened muscles in the throat below the chin and the upper chest during breathing. "Drop" the breath from the neck and upper chest down into the lower chest and abdomen. For that objective, learn how to relax your breathing and the torso muscles.
2. Learn to do diaphragmatic breathing correctly. Some people have an incorrect understanding of diaphragmatic breathing. When asked to do diaphragmatic breathing, they merely expand and contract the front of the abdomen without engaging the lower side ribs. In such a case, their lower side ribs stand still as they do "belly puffing." Correct diaphragmatic breathing involves contraction and expansion of the lower ribs in an outward motion below your armpits.
3. Practice abdominal and lower ribs breathing. It is helpful to learn both types of diaphragmatic breathing, namely, "abdominal breathing" and "lower ribs breathing."* You can learn these techniques by paying ATTENTION to the movement of breath through specific maneuvers and identifying the LOCATION (the abdomen and mid-lower ribs), discerning wherein the diaphragmatic action takes place. These patterns can be relatively easily identified through yoga postures such as the "Cobra" or the "Crocodile."
4. Engage pelvic muscles during breathing. When you can habitually maintain the breathing action in the lower chest and the abdomen, and you got the diaphragmatic breathing down pat, you may then, deliberately start engaging the lower pelvis and the pelvic floor during exhalation. If you have COPD, focus on and breathe from the midsection and below, which would get you out of the upper-chest breathing pattern? While inhaling, allow the side ribs to expand. You simply focus on side rib expansion rather than on abdominal expansion. Front of the abdomen will expand naturally as a result of side rib expansion. Begin your exhalation by slightly pulling in (squeezing) the pelvis area and move up progressively contracting the abdomen. Just bringing your mind to the above stated areas and imagining the above-specified movements can assist you in breathing correctly.
5. Practice the "full breath" technique Having mastered the diaphragmatic breathing and pelvic-abdominal exhalation, some of you may want to practice the "full breath" techniques. Full breath is a yoga breathing technique which involves "pelvis breathing," "abdominal breathing," "lower ribs breathing" and "chest breathing. For that purpose, while breathing, engage muscles in the pelvis, abdomen, lower ribs (mid-thoracic side ribs) and the chest* but not engage the neck and collar area. A relatively easier way to learn the full breath is to practice systematically isolating the breath movement in pelvis, abdomen, lower side ribs and the chest. Make sure you don't engage the neck and collarbone area, which are "secondary breathing muscles," and should be left except in an emergency.
6. Track inhalation and exhalation systematically. While EXHALING, gently press/pull in the area from bottom to below the navel and progressively pulling/pressing in the navel area, gently squeezing the side ribs and solar plexus and up to the breastbone tip (the Xiphoid Process) where the ribs join. It is important to relax and passively empty the lungs. If necessary, make only minimal and gentle effort to empty the lungs. While INHALING, keep the throat and collarbone relaxed. Remember the advice against using the secondary breathing muscles! Allow the chest to expand down to the breastbone. Progressively move the attention downward towards the lower side ribs, relaxing and let the abdomen and lower ribs movement flow naturally all the way down to the pelvis and pubic bone. In summary, while inhaling, your attention moves downward and while exhaling attention moves upward. Don't worry if the muscles initially do not contract or release as you would like them to perform. However, just forming the intention of doing so and moving your attention upward and downward is a significant start. Form the habit of taking a few full and deep breaths every day.
7. Practice conscious and deliberate brief pause after inhalation and/or exhalation. Practice holding the breath after inhalation and/or exhalation consciously for a few seconds, perhaps, two or three seconds initially or even up to ten or more seconds with some exercises. However, stay within your "comfortable zone". Staying in your "comfortable zone" means that you hold your breath without stressing or straining your system and start breathing at the first desire to breathe. If you feel desperate or rush to take the next breath, it would indicate that you held the breath a little longer than you should have. Therefore, pauses should be according to your comfortable zone THAT DAY. With practice, over a period of time, you can gradually increase the duration of the pause.

Other Breathing Training Aids

Posture Training:
While poor posture (e.g. forward head and excessive upper chest bending with back hump) can compromise your breathing by squeezing your lungs. Maintaining a good posture, such as keeping the neck, head and spine straight and relaxed) will facilitate breathing by better lung expansion. Paying attention to how you sit, stand or lie down can add more oxygen to the body through out the day. Reduce the postural problems that restrict breathing. Always stand tall, sit tall and walk tall!

Utilization of attention and intention
Utilization of attention and intention for specific way of breathing and maneuvering the body may enhance the benefits of an exercise. Pay attention to your breath when you move your spine and notice how the breath is moving into the parts of spine that are being exercised.
(Beside yoga, refer to Milton Erickson's Ideo-Motor theory including memory).

Visualization of an Exercise

"Visualizing an exercise while actually inhaling and exhaling as recommended for the exercise may be attempted for preparation and readiness for that exercise.

If you are unable to perform a specific exercise, visualize yourself performing it and actually inhale and exhale as recommended for that particular exercise. Such a "mental practice" is likely to benefit more than not performing the exercise at all."

Utilize breathing to enhance the benefits of the exercise

If not strenuous or uncomfortable, utilize breath in order to increase the benefits of a body movement or of an exercise. Breathing and body movements interact and should be coordinated to help each other, that is that breathing helps to facilitate body movement and specific body movement facilitate breathing. When performed correctly respecting the functional relationship of the breath and body, breath can augment a body maneuver (e.g. yoga posture) and a body maneuver can augment breathing.

Such linking of the breath with the body movement can benefit the breathing muscles and the entire breathing apparatus.

While correct breathing can make an activity easier, holding the breath or breathing incorrectly can make the activity harder. Use breathing effectively so you can get the most out of the poses, get stronger and have more endurance

Breath as a tool for psychosocial benefits

Slow, deep and relaxed breathing has psychosocial benefits in terms of experiencing physical and mental relaxation, mood improvement, and anxiety and stress management.

Breath and Movement Coordination

General Guidelines

1. Dominant and exertion movement normally done on inhale are usually better done on exhale (e.g. getting up from a chair).
2. Movement normally done on exhale shouldn't be done on inhale (e.g. a forward bend should not be done on inhale).
3. When making the whole body or body parts shorter (contracting/folding) - exhale.
4. When making the whole body or body parts taller (stretching/extending) - inhale.
5. When shortening the distance between torso and limbs - exhale.
6. When increasing the distance between torso and limbs - inhale.

When primary movement involves

A. Chest opening/shoulder girdle/arms expansion exercises preferably on inhale in order to strengthen inhalation muscles (If doable).
B. Abdomen/Pelvic girdle/legs squeezing (contraction) exercises on exhale in order to strengthen the exhalation muscles.

Overriding principles

A. Whenever, a movement such as going into a pose or coming out of a pose feels harder or more demanding perform on exhalation.
B. To prevent or reduce Shortness of Breath (S.O.B.) or other breath irregularity, do slow, soft and continuous breathing with or without Pursed Lip Breathing (P.L.B).
C. While exercising, if you prefer to do continuous slow and soft PLB over linking the breath and movement, please do so. Most important thing is that you don't hold your breath while exercising. Make sure that you breathe continuously while exercising.

The Five spinal movements

In a yoga exercise session, spine is moved in the following five directions:
Axial extension (vertical elongation of the spine), forward bend, back bend, side bend and twist.
1. Utilize all five spinal movements for flexibility and strength of the spine and the breathing apparatus
2. Utilize axial extension to facilitate other spinal movements.
3. The sequential order of spinal movement, axial extension (lengthening/elongation of the spinal column) first, followed by forward bend, back bend, side bend and twist. For safety of the spine, it is better to end the sequence with forward bend and axial extension.
4. The above sequential order, barring individual problems such as arthritis, pain, injury, surgery, etc. can facilitate and prepare for the next spinal movement.
Be Safe first: In case of arthritis, pain problems, joint or balance problems or other major medical conditions such as heart disease talk with your health professionals whether a pose would be advisable for your condition. If any of the poses causes discomfort check with your health professionals whether you should eliminate that pose or practice a form of the pose specially adapted for your condition. An intelligent adaptation of the pose can be even more beneficial for you than the standard pose.

Spinal direction and breath coordination

* Inhale or exhale in parentheses for "Stay" position is for individuals who utilize non-typical breathing for going into or coming out of the pose. Individuals with higher fitness levels may stay for two or more breaths in the stay position.

1. If possible, utilize functionally correct breathing to facilitate spinal movement.
2. End the spinal movements with forward bend and axial extension.

Examples:
1. Axial extension:

2. Forward-bending:

3. Backward-bending:


4. Side-bending:

5. Spinal twisting:

Ending the exercise session

It may be beneficial to end the exercise session with cool down PLB, relaxed breathing and some form of progressive muscular relaxation

Adopt a Comprehensive Program

Whole-body strengthening and flexibility

Of course, spinal health is the main target, but an exercise session must include some exercises for strengthening and flexibility of the whole body.

Other activities and exercises

Utilize other activities and exercises such as walking, hiking and using lightweights, rowing machine, treadmill, warm water pool exercises* etc., as part of your overall health and fitness program.

*if you tend to experience severe shortness of breath, you can stay at the waist level in the water to avoid pressure against your chest or use a float belt and perform exercises floating on your back and that way your chest would be free for the movements Water pool exercises are also very relaxing and soothing.

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Copyright 2006, Mind Publications 
Posted October 2006