Designing Yoga Practices for People with COPD (obstructive breathing)

Vijai P. Sharma, Ph.D., psychologist and registered yoga teacher Abstract: Overall goal, objectives, strategies, adaptation guidelines for a "breath friendly" asanas (yoga postures) strength and flexibility and breathing techniques for slowing the breathing and lengthening the exhalation are provided so yoga teachers and therapists can design appropriate practices for their students. Two sequences, one "mild" and the other of "moderate" intensity for asanas and pranayama are provided as examples.

Goal
Increase whole body endurance and strength and improve breathing efficiency

Objectives

Reduce shortness of breath and breathing discomfort
Minimize the use of neck and shoulder muscles during breathing
More efficient filling and emptying of lungs
Increase breath awareness and breath control
Increase chest and abdominal excursion (mid-section of special interest for diaphragmatic flexibility and movement)
Increase strength and flexibility of the intercostals (lower ribs of special interest for side rib breathing)
Increase strength and flexibility of the inspiratory and expiratory muscles (forced expiration of especial interest)
Increase strength and flexibility of the back muscles
Increase strength and flexibility of the upper and lower extremities
Improve posture and balance

Strategies/Techniques

Prefer gentle and slower yoga
Prior to performing a practice session, stabilize breathing and facilitate the action of breathing muscles with conscious breathing and relaxed attention
Promote breath awareness by utilizing such techniques as "counted breaths" "counting the breath duration" and "tracking the movement of breath in the body."
By utilizing the above breathing awareness techniques, help the individual to slow the breathing and lengthen the exhalation. Work on achieving exhalation at least equal or longer than inhalation.
Prefer fewer repetitions and longer stay in the poses to keep the blood flow for a loner period in the targeted areas.
As far as possible, move the spine in five directions (forward bending, backward bending, inter-vertebral extension, lateral flexion and twist) in each session
Coordinate the spinal directional movements with inhalation and exhalation to optimize the effects for spinal flexibility and strength and breathing efficiency.
Progressively slow the duration of specific movements in the yoga poses to increase endurance for the exercised body parts
Progressively increase the length of exhalation and inhalation in small increments to coordinate with the slowing of

Adaptation Guidelines for a "breath friendly" practice

Pause and rest as needed. Some individuals with respiratory challenges need more rest pauses.
Prompt de-tensing: Relax any excessive or uncalled for tension during and after the completion of the pose.
Modify intensity and pacing: Scale down the intensity of the exercise and pace as needed. If shortness of breath (SOB) is experienced, utilize Pursed Lip Breathing (PLB) or pause to stabilize the breath
Modify rules of inhalation during movement: Traditional rules of breath and movement coordination may be modified to suit the student's need. For example, a backbend may be during exhalation instead of inhalation. If needed, what is done on inhale can be done on exhale. Instruct the individual to exhale while moving into and out of the pose and inhale during the stationary position. However, when possible, backward bending should be performed during inhalation to strengthen the inspiratory muscles.
Accommodate excessive neck and shoulder rigidity: For those with excessive tension and rigidity in the neck and/or excessive involvement of neck and shoulder muscles during breathing or those who experience SOB or pain in raising the arms above shoulder level or neck turning, modify an asana to keep arms and hands at or below the shoulder level and avoid neck turning. For example, in the Triangle pose, ask the student to keep the hand behind the back and look at the floor or the front wall.
Use of props and support: Props and supports should be considered in the interest of safety and effectiveness for the desired effect of an asana and/or more efficient breathing. Prefer props which minimize strain on the breathing, maximize blood flow into the targeted muscles and organs, and augment breathing. Avoid props that are effort-intensive, expensive or require assistance of another individual in order to utilize them.

Yoga for COPD Segment 2-week 3 &4 (Mild) Designed by Gary Kraftsow* with a few modifications by the author
NOTE: Specific instructions are provided to coordinate the movement with exhalation or inhalation. However, if inhalation during a movement(s) challenges your breathing, do the movements while exhaling and inhale during the stationary position.

1.)	(Supine supported or seated) conscious breathing	6x
2.)	(Supine) arms movement (variation)	3-6x
3.)	(Supine) bridge pose	3-6x
4.)	(kneeling) cat-child pose (Optional: Uttanasna)	3-6x
5.)	(standing) warrior I Poses (A & B)	3-6x each leg
6.)	(standing) forward bend to chair Optional: Tree Pose	3-6x
7.)	(standing) triangle with chair (new)	3 each leg
8.)	(chair) forward bending	3-6 x
9.)	(supine) bridge pose (same as #3)	3-6x
10.)	(supine) knee to chest

B. Breathing

* cited with permission of G. Kraftsow
Descriptions for Segment #2

Exercise # 1: Supine/seated conscious breathing (*description bottom of the page)

Exercises #2 Arms movement: pillow may be used under the neck to relax the neck and shoulders. If strenuous, arm raise may be done on exhale.

Exercises #3 Bridge Pose: If strenuous, both pelvic raising and lowering may be done on exhale. Only if you feel up to it, you may do other arm variations such as moving over the head or sliding arms up and down in the stay position

Exercises #4 Cat-Child Pose: After completion of the Cat-Child Pose and prior to the Warrior Pose, Uttansana may be added. Optional Standing Forward Bend (Uttansana): If desired, a student may do 1-6 repetitions of Uttansana with bent knees and sliding hands up and down the legs while moving in and out of the pose.

Exercises #5 Warrior Pose: Keep the hands at the abdominal level in order to keep the shoulders down. If suitable, other arms and hands variations such as pelvic level or mid-chest level may be utilized to augment the effects

Exercises #6 Forward Bend to Chair: Keep the chair against the wall for safety. Avoid arm raise for a student with neck and shoulder rigidity. If standing and sitting each time for forward bending is strenuous, bend with hands resting on the chair and perform dynamic Ardha Utkatasana-like movements) Optional Supported Tree Pose: Stand near the wall/ chair and raise your foot at or below the knee for 1-4 breath. Then switch to the other leg for1-4 breaths. If you feel unstable, rest your hand on the chair to steady yourself.

Exercises #7 Triangle with chair: Keep the chair against the wall for safety. Unlike the traditional Triangle, look down or at the front wall. Only if comfortable, turn up the neck towards the ceiling.

Exercises #8 Forward Bending from Chair: Entire set of forward bending may be performed while sitting in the chair. For a more challenging pose, you may stand and sit down every time to bend forward.

Exercises #9 Bridge Pose: If strenuous, pelvic raising and lowering both may be done on exhale. Only if you feel up to it, you may do other arm variations such as moving over the head or sliding arms up and down in the stay position

Exercise # 10 Knee to Chest: Both the knee pressing and legs raising may be done on exhale. In such a case, press the knees to the chest while exhaling. Bring the knees away from the chest while inhaling. Raise legs towards the ceiling while exhaling.

*Description of Exercise # 1 (Supine/Seated) Conscious Breathing:

Lie down and make yourself comfortable. Put a folded blanket under your back to raise the lower and upper chest. Use additional blanket or small pillow under your neck and knees to be comfortable. Feet are comfortably apart and turned out. If you feel stress in the back, bend your knees and place feet flat on the floor. Arms at sides, palms turned up, few inches away from the body and shoulders in contact with the floor and relaxed. Relax your forehead and the entire face. Relax both arms and shoulders. Relax both legs and hips. Relax the entire upper body. Relax the whole body from head to toes. Don't go to sleep. Stay AWAKE but relaxed!

Bring your attention to your breath and let it relax. As you inhale feel the breath moving down from chest into the abdomen and pelvis. As you exhale, feel the breath moving upward from pelvis and abdomen to the nostrils. Maintain the feeling of breath flowing downward as you inhale and the breath flowing upward as you exhale. Take 6-12 breaths with such a feeling.

Adaptation: If lying down is not comfortable, sit in a chair and follow the above guidelines for relaxed and conscious breathing.

B. Breathing:

1)	(Supine) "joint breathing"	3-5 minutes
2)	(sitting) humming breath	6 x
3)	(sitting) vowel singing	6 x

1. Supine/Seated "Joint Breathing:"

(3 breaths each joint-approximately 5 minutes)

Lie down and make yourself comfortable. Use rolled blanket or small pillow under your neck and knees to be comfortable. Feet are comfortably apart and turned out. If you feel stress in the back, bend your knees and place feet flat on the floor. Arms at sides, palms turned up, few inches away from the body and shoulders in contact with the floor and relaxed. Relax your forehead and the entire face. Relax both arms and shoulders. Relax both legs and hips. Relax the entire upper body. Relax the whole body from head to toes. Don't go to sleep. Stay AWAKE but relaxed!

Bring your attention to your breath and let it relax.
Every time inhale "as if" inhaling through the crown of your head and exhale "as if" through the joint mentioned each time
Inhale as if through the crown and exhale as if through the toes (3 x)
Inhale as if through the crown and exhale as if through the ankle joints (3 x)
Inhale through the crown and exhale through the knees (3 x)
Inhale crown and exhale hip joints (3x)
Inhale crown and exhale pelvis and perineum (3 x)
Inhale crown exhale solar plexus (3 x)
Inhale crown Exhale heart region (3 x)
Inhale crown exhale pit of the throat (3 x)
Inhale crown exhale center of the eyebrows (3 x)
Inhale crown exhale back to the toes (3 x)
Inhale! Exhale as if the whole body is breathing (3 x)
Open eyes and take a gentle stretch

*If your breathing is not stabilized yet, do a few more repetitions of the whole body breathing.

2. (Sitting) Humming Breath (6 breaths):

In a seated position, press the tip of your tongue against the hard palate and make a soft humming sound such as "hummm….." As you begin to approach the end of your breath, exhale without the humming sound. Instead of producing humming sound of the beetle, if you prefer, you may sing a short line of your favorite song. Again, as you approach the end of your breath, exhale without the humming sound.

3.(Sitting) Vowel Singing (6 breaths)

In a seated position, sing the vowels (Ah, EE and OO) slowly and gently. As you begin to approach the end of your breath, exhale softly without the vowel sound.
"? ? ? ? …." 2 x
"EEEE……." 2 x
"0000….." 2 x

Exercises for Breath Awareness

How long are your exhalations and inhalations?
Count the # of beeps as you breathe in
Count the # of beeps as you breathe out
Example:
Inhalation: 4 beeps
Exhalation: 6 beeps

How many breaths you take in a minute?
Each time you exhale, count the number and keep counting for one minute.
Example, exhale 1 (inhale)
exhale 2 (inhale)
exhale 3

Where do you feel your breathing most? #1. Hands on lower tummy, middle finger tips touch navel-- 2 breaths
#2 Hands ½ way between navel and breastbone tip- 2 breaths
#3 Pinch and separate the skin at the lower ribs -2 breaths

Yoga for COPD (Moderate to Strong Practice)

NOTE: individuals with higher functional ability may follow the traditional rules of coordinating breathing with movements. However, if inhalation during movement challenges your breathing such as in a backward bending pose, exhale while going into and out of the pose, and inhale during the stationary position prior to initiating the movement.

1. Supine/Seated Conscious Breathing
2. Cat pose-Child Pose (Chakravakasana-Vajrasana) maintain some space between the abdomen and thighs in the child pose lest it compresses the diaphragm)
3. Standing Forward Bend (Uttanasana) move hands on legs while moving in and out of the pose for massage of the legs and safety of the back
4. Warrior Pose (Virbhadrasana-1) hands at abdominal level while bending backward to minimize neck and shoulder stress. (Optional Standing Forward Bend (Uttansana): If desired, a student may do 1-6 repetitions of Uttansana with bent knees and sliding hands up and down the legs while moving in and out of the pose).
5. Triangle (Trikonasana) While in the pose, place hand behind the back and looking down or front to avoid neck and shoulder strain (Optional, hand on the wall/chair and maximize the lateral stretch)
6. Standing Forward Bend (Uttanasana) move hands on legs while moving in and out of the pose and end the last repetition with Ardha Utkatasana on the floor)
7. Child Pose-Upward Dog (Vajrasana-Urdhavamukha Svanasana) (Optional: In the Cat Pose, move the spine with inhalation and exhalation 1-3 times before doing the dynamic movment (vinyasa) of Child Pose-Upward Dog)
8. Supported Cobra (Bhujangasana) hands position also called "Diamond" or "Sphinx"pose (Optional: traditional Cobra--hands behind the back or in contact with the floor below the shoulders or mid-chest) 9. Locust (Shalbhasana) with chest raised or the head resting on the floor alternately raise one leg at a time. (Optional: raise the chest first and then both legs together as in the traditional locust pose)
10. Bridge (Dwipada Pitham) (Optional arm variations such as moving over the head or sliding arms up and down in the stay position)
11. Knee-to-Chest (Apanasana)
12. Reclining Twist (Jathra Parivritti)
13. Knee-to-Chest (Apanasana)
STOP! Go to segment "B. Breathing"

Additional poses-optional 1
Knee-to-Chest-Legs to the ceiling (Apansana-Urdhva Prasarita Padasana) keep the knees bent when legs raised to the ceiling
Supported Bound Angle (Baddha Konasana)
STOP! Go to segment "B. Breathing"

Additional poses-Optional 2
Head-to-Knee Pose (Janushirshasana)
Back Stretch (Paschimottansana)
(Knee-to-Chest) (Apanasana)
STOP! Go to segment "B. Breathing" Exercises

B. Breathing

1.)	(Supine) "joint breathing"	3-5 minutes
2.)	(sitting) humming breath	6x
3.)	(sitting) vowel singing	6x

Details of Breathing exercises are provided in the 'Mild to Moderate" sequence for COPD

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Dr. Vijai Sharma
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