Understanding Breathing Disorders: A "Primer" for Yoga Practitioners

Adaptations and Guidelines for Yoga Practice: How to Make the Poses (āsanās) and Breathing Techniques Work for You

Adaptations are needed in the traditional yoga postures and breathing techniques in order to meet the special needs of the people with breathing disorders. These adaptations are based on author's own observations and experimentations on himself in the last 13 years since the COPD was diagnosed in 1994. Careful research needs to be conducted regarding the safety and benefits of these suggestions:

1. Challenge yourself but do not exceed your capacity as that could tire your lungs and temporarily lower the oxygen level in the body, called "oxygen desaturation." How rigorously and intensely you should practice asanas and breathing techniques should be determined on the basis of the severity of the physical problems and the quality of overall health and fitness and not just on the basis of the spirometric numbers. Work patiently and proceed gradually to the next level of the challenge.

2. Work on the strength and flexibility of the whole body. In view of the frequently occurring poor circulation and oxygenation, structural muscle weakness and bone density deficiency, practice poses that would address major muscle groups of the body, notably those of the legs, thighs, buttocks, pelvis, abdomen, deep muscles of the back, chest, neck, shoulders and arms. Include in your practice such poses as the Extended Forward Bend, Standing Backbend, Warrior I, Warrior II, Triangle, Revolving Triangle, Downward Dog, Locust, Cobra, Bridge Pose, Shoulder Stand.

3. Do leg work! In view of the frequently occurring leg muscle fatigue, pain and weakness, specifically utilize standing poses such as mentioned in #1 or adaptations to particularly engage muscles of the feet, legs, thighs, and buttocks. People with balancing problem or lightheadedness, may need to hold on to something such as a chair or table or stand near the wall or stand in a corner where one has the support of the wall on both sides. Wall or props supported poses can generally produce comparable muscular effects with minimal energy expenditure which is important for people with breathing challenges.

4. Keep the diaphragm free and unobstructed. Some people find it difficult to breathe and/or move their diaphragm in supine position such as in Cobra or in prone position such as in Urdhava Prasarita Padasana--"Reclining Legs Up Pose"). Supine poses may be uncomfortable for some if the diaphragm is compressed or inhibited in its movement. For some prone position may be difficult if the diaphragm has problem in relaxing (moving up) against gravity during exhalation. Make sure that you are comfortable in supine or prone position before you attempt challenging poses in those positions. Adaptations can be made of almost all poses in chair seated position.

5. Increase spinal flexibility and strength. Your daily practice routine must include moving the spine in the five directions, that is, forward bends, backbends, side bends, twists and vertical elongation of the spine for not only the strength and flexibility of the spine but also for the strength and flexibility of the muscles of respiration, particularly the diaphragm.

6. Coordinate your breathing with the spinal directional movements. In author's experience spinal movements in the five directions generally coordinated with exhalation but sometimes with inhalation as well are particularly beneficial for breathing.

7. If indicated, eliminate any faulty breathing pattern you may have such as chest breathing or paradoxical breathing. Examples of paradoxical breathing during inhalation: Abdomen drawing in rather than "bulging out" or chest contraction rather than expansion.

8. Target the diaphragm and lower ribs specifically. Some poses (e.g. Reclining Abdominal Twist-Jathara Parivritt ) are particularly beneficial for exercising the diaphragm and the lower ribs. Note when the lungs are impaired the diaphragm goes through important changes. Carter and Williams say that the chronic lung hyperinflation can shorten the diaphragm and contributes significantly to diaphragm weakness which can compromise its ability to move the breath. Respiratory muscles working under constant overload and stress may contribute to dyspnea, muscle fatigue and exercise limitation. The following changes may also occur: diaphragm and the lower ribs may become rigid and inflexible; lower ribs may lose their natural curved shape and become straighter; chest deformity and the chest and abdominal muscles may become weak and floppy. With appropriate adaptations use the power of abdominal muscles and exhalation and in order to exercise the diaphragm and lower ribs. For that purpose, experiment with these and other poses: Cat Pose (Chakravākāsanā) Expanded Leg Intense Stretch Pose Prasārita Padāsanā in which you alternate touching one foot with the opposite hand, Bridge Pose (Setu Bandhasana)

9. Focus working on abdominal muscles used in forced expiration, namely, transversus abdominus, external and internal obliques and rectus abdominus. In author's opinion if you work on forced expiration, not only it would help with your exhalation but to some extent also help with your inhalation. You can work on forced expiration muscles in the stay position during forward bends, side bends and twists.

10. If required, improve your posture in order to facilitate the movement of your diaphragm. Poor posture (e.g. forward head with excessive kyphosis) can shorten the lung area and inhibit the movement of the diaphragm. Excessive use of the accessory breathing muscles and shortened and weakened diaphragm would further affect the posture. A healthy diaphragm supports the posture but compromised diaphragm may not. In one study researchers demonstrated that when the diaphragm can only do one thing, either to do the job of breathing or support the posture, diaphragm chooses breathing over the posture. Of course, you should work on all skeletal muscles and augment the integrity of spinal curvatures for better posture. However this author stresses the importance of working on the "foundation" of the posture, that is, the muscles of the legs, thighs, buttocks, pelvis and perineum. To that end, work on these muscles for example, during the stay position in such poses as the "Plank Pose, Bridge Pose or Cobra."

11. If you have scoliosis of the spine, try to modify it. Scoliosis can restrict the movement of the diaphragm which is already compromised by the disease. This author has utilized two yoga programs for his scoliosis.

12. Energy conservation is important for people with breathing challenges. By reducing the "work load" on your breathing muscles you can stay longer in the poses. This could mean departing from the traditional teaching regarding coordination of the movement and breathing. For example, exhaling while going into a backbend (e.g. Warrior I) or coming out of a standing forward bend (e.g. Extended Forward Bend--Uttanasana) will be relatively easier but inhaling could significantly increase the work load at least for some people. Kraftsow says, "Whatever is normally done on inhale (e.g. backbend) can be done on exhale. However, what is normally done on exhale (e.g. forward bend) should not be done on inhale." This guideline can be very helpful for many people with breathing challenges.

Spinal direction and breath coordination guideline

*Inhale in parentheses for dynamic and stay positions is optional for people at higher fitness level. If you are severely challenged avoid them until you've made sufficient progress. If you prefer do continuous soft breathing or PLB while practicing poses all the time or when you suspect your breath and/or heart is speeding up. To be cautious, exhale while moving in and out of the poses and inhale during the stay or neutral position. But if it is not strenuous inhale while going in, staying or coming out of a pose. Curb the tendency for holding breath unless intentional.

13. Augment diaphragmatic breathing (DB) with breathing coordinated āsanās. Do not practice DB for the sake of DB. For example, don't tell yourself, "DB is good so I will sit here and do DB for next 10 minutes" for the following reasons: 1) there is a great deal of controversy whether DB is beneficial at all for the breathing challenged 2) there is universal consensus on what exactly DB is and how it should be taught and 3) faulty DB method or inadequate prior preparation for DB may cause you to inhale more air than you can exhale resulting in excess stale air in the lungs. Author's preference is to cultivate the DB pattern by working on the strength and flexibility of the diaphragmatic muscle, the lower ribs, entire ribcage mobility and the chest muscles while coordinating these exercises with your breathing. Some of the preferred poses for this purpose are mentioned in the suggestion # 7.
14. Savāsanā (Relaxation Pose) and/or other forms of muscular and mental relaxations in supine or chair position indeed are most important ?san?s for people with asthma and COPD and ideally should be practiced at least twice a day 15 to 20 minutes each time. Unless there is a mechanical or structural limitation, whole body and mind relaxation should automatically restore DB.

Goal: To move the spine in all five directions coordinated with breathing during a 20-30 minute practice with additional 15-20 minutes for Savasana, preferably two practices a day.

Some poses consist of more than one spinal directional movements, for example, Chakravakasana (Cat Pose) involve forward bending and back bending. The spinal directional movements also depend on the intention and adaptations on the part of the practitioner. For example, a simple sitting or standing posture can be utilized for forward bending, back bending, lateral bending, twist and extension of the spinewith manipulation of the arms and legs. You may utilize any light forward bending pose/s intermittently during your practice to normalize your breath with or without PLB or to correct your posture. For example, after Ushtrasana (Camel Pose) do Balasana (Child Pose) or after a Trikonasana (Triangle Pose) do Uttanasana (Standing Forward Bend). Forward bends are particularly good for slowing the breathing and lengthening exhalation.

Practitioners may make adaptations with proper supports and props for their level of conditioning to receive similar benefits as the ones offered by the standard format of the pose. These supports are generally available in every household: Wall, wall corner, chair free standing or by the wall, kitchen or sink counter, dining table or 16-18" high bench (or a standard press bench), etc. These props may offer ease and comfort to help achieve the intended benefits of a posture: Pillows, bolsters, blankets, bench, belt, blocks, etc.

Poses listed below with suitable adaptations may be explored by the breathing challenged. Some of these poses can be demanding for some people as they are intended to cover a wide range from high level to low level of conditioning. But, with suitable adaptations, supports and props, their intensity can be significantly reduced. Samskrita and English names of these poses to a large extent are taken from Kraftsow and Iyengar Books by these authors and the DVDs specially designed for people with COPD by the present author can also be utilized to generate ideas for adaptations.

Forward Bends: Tadasana (Mountain Pose) preferably arms down; Agnisara (standing with hands on upper thighs or knees); Uttansana (Standing Forward Pose); Parshvottanasana (Extended Side Angle Stretch); Prasarita Padottanasana (Expanded Leg Intense Stretch); Ardha Utkatasana (hands in contact with the floor); Adhomukha Svanasana (Downward Facing Dog); Paschimottanasana (West Side Stretch); Janu Shirshasana (head on the knee of the stretched leg) Balasana (Child Pose) with forehead on double fists or blocks

Backbends: Backbend in the Tadasana; Virbhadrasana (Warrior I) with arm variations but watch for shoulder and neck tension and fatigue; Chakravakasana (Cat Pose); Godhapitham; Viprita Dandasana (Inverted Staff Pose) on chair or a ball against the wall; Ushtrasana (Camel); Bhujangasana (Cobra); Supported Viparita Karni (supported Inverted Lake Pose); Setubandhasana (Bridge Pose)

Lateral Bends: Tadasana (Mountain Pose) with arm manipulation; Utthita Trikonasana (Extended Triangle); Utthita Parshava Konasana (Extended Bent Knee Stretch); Jathra Privritti (Abdominal Twist) lateral variation: Lateral bends in Prasarita Padottansana; Lateral bends seated position in chair or on the floor

Spinal Twists: Twist in Tadasana or Prasarita Padottansana position with spread arms; Trikonasana Parivritti (Revolving Triangle); Utthita Marichyasana (Standing Spinal twist with one foot on a chair or table); Ardha Matsyendrasana (One leg stretch and one knee standing); Twist in Staff Pose or floor or chair seated position; Jathra Parivritti (Abdominal Twist)

Extension of the spine: Extend the spine with arms manipulation in any standing, kneeling, seated, supine, or prone position; Salamba Sarvangasana (Supported Shoulder Stand against the wall); Stretch the spine in Shavasana (Corpse Pose) or Tadakasana (Lake Pose); Mahamudra (Upward Facing Single Leg Stretch with one knee bent); Apanasana (Wind Relieving Pose) with knees towards the chest in supine position; Urdhava Prasrita Padasana (upward spread feet in supine position); Supta Baddha Konasana (Reclining Bound Angle Pose);.

Shavasana: The best for the last. End the practice with Shavasana for 15-20 minutes.

Makrasana: If you have an extra 5 minutes, do Makrasana to continue the theme of relaxed diaphragmatic breathing (DB). Lie down on your belly with your forehead head on the forearms of the bent elbows with the chest off the floor and the belly pressed against the floor.* Make adjustments until you can get into a comfortable and relaxed position. Relax mentally and physically. Notice the movement of the breath in the front, the back and the lower side ribs. In this context, Makrasana is used as a pose for relaxed DB.

*If you do not like the diaphragm pressed against the floor, you may skip this exercise.

Exercises for Breath Awareness and Controlled Breathing

Breath awareness is instrumental for assuming control of breathing. For example, it helps to know the number of breaths you normally take in a minute, the length of your normal exhalation and inhalation, and how much these numbers change when you are under stress and excitement.

Breathing in Stillness

In order to perform the exercises for breath awareness and breath control, sit or lie down in a comfortable but in a straight and well aligned posture. Relax mentally and physically, preferably in a state of deep relaxation or meditation. To measure the length of your breath, count silently in your head, e.g. "One thousand one" "One thousand two" "One thousand three." It takes approximately one second to silently say, "one thousand one," but you may utilize other methods for tracking time such as a stopwatch or a metronome beep.

Never strain your breath. Stay within your comfortable capacity. If your experience heart start racing, shortness of breath or rapid breathing, stop! Take a few normal breaths or do PLB until you are breathing normally.

1. Determine your usual breathing rate: Count the number of breaths you take in one minute at rest in different body positions, namely, sitting, lying down and standing. Simply count the number of your exhalations for one minute to calculate the total number of breaths in one minute.
2. Determine your breathing rate under stress: Count the number of exhalations for one minute when you are feeling anger, anxiety, sadness, excitement and mental, physical or emotional stress.
3. Determine the normal length of your inhalations and exhalations (I/E): Count silently as you start inhaling, for example, "One thousand one" "One thousand two" "One thousand three" and so on until the end of the inhalation. Count similarly during the exhalation.
4. Lengthen your exhalation relative to inhalation as I/E 1 to 1.5 or 1: 2. For example, if your inhalation is to a count of 4 seconds, gradually increase exhalation to a count of 6 seconds and then for 8 seeonds, if possible.
5. Lengthen both your inhalation and exhalation while maintaining the I/E ratio of 1 to 1.5 or 1:2
6. Practice "cyclical breathing." Let your inhalations smoothly transitions into exhalation and vice versa forming a continuous cycle of smooth breathing.
7. Relax and count your exhalations backward starting from 10 to 0. Over time increase the top number such as 20 to 0 or even 30 to 0. When lose track of the count, start all over again.
8. Work on slowing down your breathing from 12-15 b/m to down to 6-, 5- or 4 b/m still maintaining exhalation longer than inhalation. For example, in 4 breaths a minute, inhalation may be for 6 and exhalation for 9 seconds.
9. Practice "end-inhalation breath holding." After normal inhalation, briefly hold your breath for 1-4 seconds. Gradually over time increase the breath holding time (BHT) to 5 or 6 seconds.
10. Practice "end-exhalation breath holding." After normal exhalation, briefly hold your breath 1-2 seconds. Gradually, over time, increase BHT to 3 seconds or longer.
11. Practice both "end-inhalation breath holding" and "end-exhalation breath holding" in the same breath cycle. You may keep end-inhalation BHT longer than end-exhalation BHT. Be patient and take your time in increasing BHT.
12. Practice under breathing. Deliberate and conscious under breathing is opposite of what yogis usually ask "Take a long breath" or "Breathe deeply." But during times when you are constantly breathing rapidly, lungs are hyper inflated and CO2 level is going down lungs, taking small and shallow breath and prolonging the pause between in breath and out breath may help you to slow down your breathing. Mindfully and gradually take small and shallow breaths and when the breath seems to be calming down, work on lengthening the pause.
13. Practice 2-stage exhale (Viloma Krama). Inhale! Exhale first half of the breath while gently contracting abdomen from pubic bone to the navel and then exhale the second half of the breath while gently contracting from navel to sternum.
14. Practice modified alternate nostril breathing (ANB). ANB can be of two types: 1) exhale from the left nostril-inhale from the left-exhale from the right and inhale from the right, thus completing one cycle 2) inhale from the left-exhale from the right-inhale from the right and exhale from the left thus completing one cycle. You may do a few cycles of both types of ANB.
15. Humming breath: Softly hum any verse or phrase you like or do Omkara (Ommm) for a few breaths. Each time inhale slowly, hum softly without straining the breath and and gradually lengthen your exhale.
16. Vowel chanting: Chant Ommm or vowels such as "aahmmm" "ooommm" "eeemmm" etc. Each time inhale slowly. Without straining your breath, gradually lengthen your exhale.

Breathing in Motion

• Count your breaths while walking e.g. 1 to 100. After reaching 100, start again from 1. If lose the track of number, start all over again with 1.
• Walk while maintaining your breathing rate between 12-15 b/m. Over a period of time practice walking at the rate of 6 b/m
• Perform other exercises (e.g. tread mill or bicycling) as well while maintaining the normal rate of 12-15 b/m and progress to 6 b/m

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Copyright 2007, Mind Publications 
Posted March 2007