INTERNATIONAL JOURNAL OF YOGA THERAPY - No. 17 (2007) 81

Yoga Therapy in Practice

Yoga for AsthmaDeborah Morse, RYT, FNP-CDuke Medical Center Dept. of Anesthesia; The Yoga Practice Center. Durham, North Carolina.

Abstract

This article reviews relevant research on the possible benefits of Yoga interventions for individuals with asthma. Research suggeststhat Yoga, especially when practiced with inclusion of the whole of its traditional techniques (including asana, pranayama,meditation, and relaxation) provides benefit for asthma sufferers. The article then offers suggestions for Yoga teachers and Yogatherapists who would like to develop a Yoga practice for students with asthma. Specific pranayama and asana practices aredescribed. The recommended practices will help students with asthma develop a new awareness of how physical posture andbreathing techniques can minimize the frequency and severity of asthma episodes.

Introduction

Airway constriction in asthma is a complex and oftennot fully understood process. Because asthma has manypossible contributing factors, including exercise, allergicreactions, air pollution, emotional factors, and genetics, itis best to consider a multifaceted approach to preventionand treatment.' In a review of nontraditional approachesto asthma, Perlman and Serbin^ reported that Yoga is ahelpful complementary therapy for asthma. Holistic ap-proaches to asthma care can iinclude establishing a regularand effective Yoga practice that includes Asana, prdndyd-ma, and meditation. It is these methods combined, ratherthan any individual Yoga technique, that seems to offerthe most benefit.

Breathing Difficulties in AsthmaAsthma is characterized by a combination of increased

mucous production, thickening of airway tissue, smoothmuscle contraction around airways, and hyperinflation ofthe lungs. Individuals with asthma experience a decreasedability to exhale, and residual air held is within the lungsafter exhalation. Vital capacity (the capacity for air ex-change within the lungs) is decreased. These symptoms canbe triggered or made worse by emotions, stress, and otherpsychosocial factors.^^ Chronic asthma can lead to chronicinflammation and loss of lung tissue elasticity.

The breathing difficulties associated with asthmacan lead the asthmatic individual to try many breath-ing adaptations, such as spontaneously assuming pursedlip breathing to steady and improve the flow of breath.However, many other adaptations are more harmful thanhelpful. For example, individuals may increase their re-spiratory rate during an asthma attack in an attempt toincrease oxygen and carbon dioxide exchange. However,this leads to a loss of carbon dioxide levels in the bloodstream and spinal fiuid to below normal levels, causingcerebral arterioles to constrict, and leading to reducedoxygen delivery to the brain. 'Ihis can trigger fatigue, ir-ritability, lightheadedness, inability to concentrate, andpanic attacks.̂ 'PP^ -̂'«-""''̂ «'

Individuals with chronic asthma also rely more on ac-cessory respiratory muscles such as the intercostals ("be-tween the ribs"). There may also be a tendency to lift theshoulders forward and up in a compensatory attempt tocreate more lung space and movement with each breath.This postural adaptation actually reduces breathing effi-ciency and the ability to fully exhale. Lung spaces are filledwith stagnant air, and the amount of fresh oxygen brougbtin for the capillaries to absorb is reduced.

These compensatory adaptations must be addressed.Breathing and posture training, including Yoga methods,provide an opportunity to increase awareness and createhealthier breathing patterns.

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Research on Yoga and AsthmaSeveral studies have looked at the effects of Yoga

practices on breathing quality. In a study of individu-als without asthma, a Yoga-based guided relaxation ledto decreased oxygen consumption and increased breathvolume.^ Combining Yoga postures with periods ofmeditation was found to be better at decreasing oxygenconsumption and increasing tida! volume {volume of airexchanged during a breath) than relaxation alone.^ Bothof these studies suggest that Yoga practice improves theefficiency of relaxed breathing.

Looking specifically at the effects of Yoga techniqueson individuals witb asthma, one study found that airwaysbecome less reactive with the practice of Yogic meditation/'and another study showed a simiiar effect from practicinga Yogic breathing technique.'" In this second study, the air-ways of asthmatics reacted less strongly to a histamine chal-lenge test, which is similar to inducing an allergic type ofasthma episode. It is worth noting that this study used the"pink city breathing device," which requires slow breathingand extended exhalation, to teach the participants how topractice the Yogic technique.

Two studies found that training in a combination ofYoga poses, breath-slowing techniques, and meditationreduced the number of asthma attacks per week, the useof asthmatic medication, and improved peak expiratoryflow rate."'^ Another study found that university stu-dents trained in Yoga postures, relaxation, and breathingtechniques showed an increased tolerance for exercise anddecreased use of asthma medications.'^

As indicated above, practices that slow and deepen thebreath may be the most helpful for asthma. Research on asimilar (non-Yogic) breathing technique, Buyteko breath-ing, provides further evidence for this. Buyteko breathingwas developed in the 1960s as a method of treating orimproving asthma symptoms through nasal breath modi-fying techniques similar to some prdndydma methods.A randomized controlled trial of the Buteyko techniqueshowed symptom improvement and decreased bronchodi-lator use."*

More generally, Yoga practices of relaxation and con-trolled breathing reduce stress-associated increases in sym-pathetic activity,'^''' which may help individuals prevent orrecover from asthma attacks.

Research on the benefits of Yoga needs to be consideredcarefully. As with most complementary modalities, researchon Yoga is challenged by the holistic principles of the prac-tice. Yoga is inherently multifaceted, and cause and effect arenot easily defined or quantified.

Asana and PrhnhyhmaSuggestions and Precautions

The first precept for any Yoga practice should be ahimsa(nonviolence) or "do no harm." Under the guidance of aqualified Yoga teacher, the following breathing practices andposes can be modified to fit the individual needs of tbe pa-tient or client. Yoga techniques should complement medicaltreatment, and prescribed medication or other treatmentshould continue as prescribed by the healthcare provider.The student should be directed to consult witb a healthcareprovider before beginning dsana oi prdndydma instruction.

Aims of a Yoga PracticePrdndydma techniques alone and with dsana practice

teach the student new methods of engaging the breath. Evenin tbe throes of a full-fledged asthma episode, tbe studentcan begin to recognize breathing patterns and experiencesome control over the breath.

Initial assessmentEach encounter should begin with an assessment of the

client/student. Asthma symptoms are intermittent, and dif-ferent practices are appropriate for non-symptomatic andsymptomatic periods.

The student should always be asked, "How comfort-able is your breathing today?" A numeric scale (1= extremediscomfort, 10= total ease) is usefiil in helping the studentcommunicate his or her subjective perception. The student'sdegree of comfort or discomfort will guide the teacher'sinstruction either to a more energizing and strengtheningpractice, or to a calming and cooling practice.

In addition to the student's subjective response tothis scale, tbe Yoga teacher/therapist needs to observe thestudent for signs of respiratory difficulty. Signs of distressmight include:

• Rapid respiratory rate• Strained facial expression• Breathing through pursed lips• Lifting tbe shoulders toward the ears during

inhalation• Muscular tension around the neck and clavicles• Wheezing or cough• Breath strain during or following activities such

as walking a short distance across the room ormoving in and out of poses

If any of the above signs are evident, the student maybe experiencing an actual or impending asthma attack. Thestudent may obtain relief from inhaled or other medication.

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but if the condition does not improve, the student may needclearance from the healthcare provider to proceed. Delay inseeking medical care in a timely manner when experiencingsymptoms of an acute asthma attack is unsafe and contra-dicts the precept ofahimsa.

General Benefits o/^Pranayama PracticeMethods that slow and deepen breathing seem effective

for those with asthma. Slowing the breath insures that thevolume of inspired and expired air is maximal, and reducessymptoms of stress and anxiety. Prdndydma practice encour-ages breathing through the nose, which warms and purifiesthe air as it enters the lungs, and also provides for a longerand more complete exhalation.

Specific Pranayama or Breathing PracticesThe following techniques can be helpful for individuals

with asthma, although not all techniques will be appropriatefor all individuals. Always begin with the student's comfortlevel, and encourage the student to observe and communi-cate the effects of each practice.• Ujayyi (breathing): If done very lightly with

emphasis on extended exhalation, ujayyi breath-ing can be helpful in training the mind to followthe flow of the exhalation to completion. Thesound gently directs the attention back to breaththrough distraction, anxiety, or pain. Do not usethis breath if an asthma attack is approaching, asit requires the upper throat area to close slighdy ata time when everything needs to instead remainvery open.

• Viloma (three-part breathing): This completethree-part breath slows breathing by creating smallpauses within and between the breath cycles. Payingattention to the movements of the belly, lower ribs,and upper ribs can be helpful. During an asthmaepisode, this method may be more beneficial ifdone with very brief pauses during inhalation, toencourage maximal entry of oxygen, and long,slow, uninterrupted exhalation. A possible visual-ization during this breathing technique is to "fol-low the breath up a silken thread and down again,"which emphasizes smoothness and continuity.

• Extended exhalations: Start by making inhalationand exhalation even in length if the exhalationseems shorter. Once equal, proceed to a 1:2 ratio ofinhalation to exhalation. Begin where the studentis, and proceed at his or her comfort level. Engagingmula bandha and uddiyana bandha on exhalation

will help teach the student how to exhale fully bysupporting the diaphragmatic movement.

• Alternate nostril breathing: This technique canslow down the breath, and its calming effect bal-ances the nervous system's sympathetic and para-sympathetic activation.

• Yoga chair breathing: To practice this technique,have the student sit on a chair facing the back ofanother chair. Have the student place the arms onthe back of the chair he or she is facing, to lift andopen the ribcage. Inhale while gradually lifting thehead and spine and opening the chest. Then exhalewhile moving the spine, chest, and neck into gentleflexion. Do five times. Then repeat the sequenceproducing the sound "ah" while exhaling five times,then the sound "mmm" five times while exhaling.Engaging the voice teaches smooth, continuous,and complete exhalation, and also encourages com-plete engagement of the accessory abdominal mus-cles through uddiyana bandha during exhale. Thissupports fuller emptying of the residual air beforethe next inhale, increasing breathing efficiency.

• Kapdlabhdti (breathing): When begun gendy andadvanced with comfort, this technique emphasizesexhalation and can have a purging effect on the en-

• tire airway, from bronchioles upward through thelarynx and nasal passages. This can help to cleatmucous secretions that may accumulate due to in-activity, upper respiratory infection, and allergies.

• Contraindicated practices: Prolonged breath holdingand forceful rapid breathing techniques should notbe part ofa program for individuals with asthma.

General Benefits o/'Asana PracticeBreath awareness during dsana provides the student the

opportunity to become intimately aware of how certain posi-tions prevent or assist full inspiration or expiration. The useof dsana to improve posture—particularly by lengthening thespine and opening the front body—will increase breathing ca-pacity and maximize the effects of diaphragmatic movement.

Developing Breath Awareness in AsanaBreath awareness in dsana is a form of svadhiyaya, or

self-study. The key to using dsana to learn to breathe better isdiscovering how altering one's physical posture can increasebreathing potential.

One method for increasing awareness is to have thestudent change his or her posture after inhaling or exhal-ing "completely." For example, have the student inhale in

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tad^ana, witb hands and arms folded forward and togetherin anjali mudra. Then have the student open the arms wideto the sides and notice the spontaneous further inhalationthat occurs. For exhalation, have the student exhale with thearms wide and then draw the hands/arms to anjali mudra.The student will notice that even more exhalation is nowpossible. This simple technique demonstrates clearly to thestudent how connected breathing capacity and posture are.

This technique can be referred to as mild resistive tech-nique, and can be applied to any of the traditional dsanas.Provide mild resistance at first to the inhalation or exhala-tion by beginning in a pose that opposes the complete inha-lation or exhalation. Then have the student move to a posethat opens the breath or completes the exhalation. The initialmild resistance allows the student to strengthen respiratorymusculature. Vital capacity is increased as the breath is fullymoved in or out when shifting to another position within thepose. There is no kumbak or breath retention/holding, onlyopponunity to open further, assisted by posture change.

Bandhas can also be used as a resistive technique. To doso, have the student engage the mula and uddiyana bandhasas inhalation begins, then release the bandhas to allow deeperinhalation through further diaphragmatic descent. The oppo-site can be done with the exhalation, engaging bandhas afteran exhalation to allow for an even more complete exhalation.However, if the student is not at a good comfort level, leave thissubde resistive technique until asthma is under better control.

Take care tbat the student is not holding the breath withthis technique. Note that this technique is not advised whenthe student is suffering from symptoms of asthma or anydistress in the moment witb the breath. Instead, the studentshould focus on practices that lengthen the exhalation.

Special Asana Considerations for Asthma:Avoiding Gastro-esophageal Reflux

Some poses can potentially trigger or worsen asthmasymptoms. Avoid poses with the head below the abdomento prevent gastro-esophageal reflux, which can cause airwayconstriction and trigger or exacerbate an asthma attack.'*'^"Also avoid doing poses for two hours following a meal. Proneposes with abdominal compression such as locust {shalabhdsa-nd} and cobra {bhujangdsana) may induce reflux even on anempty stomach. Focus on standing and sitting poses in whichthere is no external compression of abdominal contents.

Yoga Poses that Promote Healthy BreathingThe following poses may be practiced in the order listed,

or in a sequence that follows basic principles of sequencing.If tbe student is having asthma symptoms, limit poses to the

last three on the following list. These three poses are morerestorative and concentrate on extending the exhalation.

Cat/dog lilts with resistive technique: See photos 1-3.Start on hands and knees in table pose. From table pose, ex-pand chest up and away from the belly in dog tilt (or some-times called cow) on inhale, and then contract tbe belly,round the low back (cat tilt), then lower chest to thighson exhale in child's pose. Inhale to return up to table andrepeat five times. This flowing sequence promotes thoraco-diaphragmatic breathing and strengthens the abdominalmuscles. To apply resistive technique, begin inhaling afierresting in child's pose, then continue upward to dog tilt tohave the student experience spontaneous full inhalation. Toreverse, begin exhaling while in dog tilt, then transition tocat tilt and child's pose again and notice the significant deep-ening of the exhalation. This sequence strengthens musclesof respiration (diaphragm, abdominals, and intercostals).

Cohra {bhujangdsana): See photos 4-5. This posepromotes thoraco-diaphragmatic breathing, stretchesthe chest, strengthens tbe upper back and shoulders, and di-minishes kypbosis. Tlie resistive tecbnique may be introducedhere by having the student begin in full prone positioti withforehead resting on floor, taking an inhalation before lifting tofiill effort, then lifting up smoothly into cobra and noticinghow the inhalation can open further. Reverse by exhaling tofull effort in the uplifi; of cobra, and then allow the torso tocome back down to the floor and notice the ability to exhaleeven further. Beginning the exhalation in cobra strengthens tbeinternal intercostals by offering mild resistance to the exhalation,thus strengthening muscles that assist fiill exhalation.

Sage twist {marichydsana): See photo 6. This posestrengthens the diaphragm, intercostals, and abdominaloblique muscles wben it is practiced in an upright positionwith an engaged core. The spine lengthens and lifts with theinhalation and the twist deepens on tbe exbalation. Have thestudent visualize the torso as a large sponge (whicb the lungtissue actually looks like) tbat can soak up and squeeze outoxygen. External oblique intercostal muscles are strengthenedhere due to the mild resistance to inhalation tbe twist pro-duces, and the paraspinal and shoulder muscles are given agood stretch, releasing the ribs to expand and contract morefreely. Priority should be given to lifting the spine fully ratherthan the degree of twist obtained. Have the student decreaseeffort if the student tends to hold tbe breath on the twist.

Mountain pose {taddsana) with back to wall: See pho-tos 7-8. Special attention is given here to maintaining orrecovering normal spinal curvature. This pose opens theribcage, strengthens the back, improves spinal alignment,and strengtbens the diaphragm via thoraco-diapbragmatic

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breathing. Have the student observe the deepening of ex-halation when moving the arms inward to anjali and thedeepening of inhalation when opening the arms outward.Tadasana also offers an opportunity to focus on engagingmula bandha and uddiyana bandha on the exhalation.

Downward facing dog pose {adho mukha svandsana):See photo 9. Modify to use a wall or table if a sinus in-fection, gastro-esophageal reflux, or asthma is symptom-atic. This pose diminishes kyphosis and opens the shouldergirdle. This also is a good pose to again practice mula anduddhiyana bandha to support full exhalation.

Pyramid pose iparsvottandsana): See photos lO-11.Begin upright while catching elbows or strap behind thebody, and move toward a gentle backbend to increase lungspace. Then move forward with the spine fully extended,not collapsing lung space. The forward fold will assist infiiil exhalation. Engaging mula and uddiyana bhandas willfiirther support the movement and exhalation.

Side angle pose (parsvokondsana): See photos 12-13. Thispose promotes thoraco-diaphragmatic breathing, stretchesintercostals, strengthens paraspinals, and can reverse scoHosiswith attention to stretching the contracted side of the spine.Use resistive technique here by coming into tbe pose with theupper arm resting along tbe side and hip. Inhale to full effort,then reach that arm overhead to funher open the inhalation.Work in reverse by beginning the exhalation with the armextended, then sweep the arm back to the side and notice theexhale deepen. Keep transitions fluid, so tbere is no breathholding, only a slight pause, as in viloma breathing.

Fish pose {matsydsana): See photo 14. This pose opensthe rib cage, deepens the breath, and reverses kyphosis. Analternative to this is supported fi.sh (using blankets or bol-sters to support the basic shape of the pose) if a more restor-ative and passive pose is needed.

Sitting forward fold {paschimottandsana): See photo 15.Allow the pelvis to hinge forward away from the top of thefemur bone to prevent moving into cat tilt and collapsingthe anterior torso. Keep the upper shoulders and neck arearelaxed, and use gravity to release outward and Forward tocalm and soothe the nervous system.

Elevated supine corpse pose {savdsana): Elevate thetorso on a bolster or blankets with additional support forarms and legs to the student's comfort. The anterior mus-cles and lung space can stretch and expand passively in thisposition. With the torso elevated, the mechanical weightof tbe abdomen upward on the diaphragm is reduced, al-lowing for a full inhalation and a long, relaxing exbalation.Relaxation may be taken in this restorative posture. Thispose is useful for training the body and mind to full relax-

ation, and for minimizing the likelihood and effects of apossible asthma attack.

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Direct correspondence to Deborah Morse zx fireflyyoga(^c. rr.com.

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