Evidence-Based Yoga Therapy for Older Adults (Page 2)

A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis (clot), arterial embolism (floating clot), or a hemorrhage (leakage of blood). Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply (usually by a clot), while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia and the remainder by hemorrhage. As a result, the affected area of the brain is unable to function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. It is the leading cause of adult disability in the United States and Europe and the second leading cause of death worldwide. Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. Every year, 600,000 people have strokes.  2/3 of these people are over the age of 65 and 25% of these people die as a result.  Of the survivors, 25% will be permanently disabled.  There are currently 4.5 million stroke survivors living in the US. 

Conventional Treatment for Stroke
For most stroke patients, physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) are the cornerstones of the rehabilitation process. Often, assistive technology such as a wheelchair, walkers, canes, and orthosis may be beneficial. PT and OT have overlapping areas of working but their main attention fields are that PT focuses on joint range of motion and strength by performing exercises and re-learning functional tasks such as bed mobility, transferring, walking and other gross motor functions. Physiotherapists can also work with patients to improve awareness and use of the hemiplegic side. Rehabilitation involves working on the ability to produce strong movements or the ability to perform tasks using normal patterns. Emphasis is often concentrated on functional tasks and patient’s goals. One example physiotherapists employ to promote motor learning involves constraint-induced movement therapy. Through continuous practice the patient relearns to use and adapt the hemiplegic limb during functional activities to create lasting permanent changes. OT is involved in training to help relearn everyday activities known as the Activities of daily living (ADLs) such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. Speech and language therapy is appropriate for patients with the speech production disorders: dysarthria and apraxia of speech, aphasia, cognitive-communication impairments and/or dysphagia (problems with swallowing).
Patients may have particular problems, such as dysphagia , which can cause swallowed material to pass into the lungs and cause aspiration pneumonia. The condition may improve with time, but in the interim, a nasogastric tube may be inserted, enabling liquid food to be given directly into the stomach. If swallowing is still deemed unsafe, then a percutaneous endoscopic gastrostomy (PEG) tube is passed and this can remain indefinitely.
Treatment of spasticity related to stroke often involves early mobilizations, commonly performed by a physiotherapist, combined with elongation of spastic muscles and sustained stretching through various positioning. Gaining initial improvements in range of motion is often achieved through rhythmic rotational patterns associated with the affected limb. After full range has been achieved by the therapist, the limb should be positioned in the lengthened positions to prevent against further contractures, skin breakdown, and disuse of the limb with the use of splints or other tools to stabilize the joint. Cold in the form of ice wraps or ice packs have been proven to briefly reduce spasticity by temporarily dampening neural firing rates. Electrical stimulation to the antagonist muscles or vibrations has also been used with some success.
Stroke rehabilitation should be started as quickly as possible and can last anywhere from a few days to over a year. Most return of function is seen in the first few months, and then improvement falls off with the "window" considered officially by U.S. state rehabilitation units and others to be closed after six months, with little chance of further improvement. However, patients have been known to continue to improve for years, regaining and strengthening abilities like writing, walking, running, and talking. Daily rehabilitation exercises should continue to be part of the stroke patient's routine. Complete recovery is unusual but not impossible and most patients will improve to some extent: proper diet and exercise are known to help the brain to recover. Disability affects 75% of stroke survivors enough to decrease their employability and stroke can affect patients physically, mentally, emotionally, or a combination of the three. The results of a stroke vary widely depending on size and location of the lesion and dysfunctions correspond to the areas in the brain that have been damaged. Some people have a great deal of disability and others very little.

Yoga for Stroke Survivors
For stroke survivors that have completed their course of rehabilitation, yoga can provide a means to continue the strength, flexibility and balance training that was initiated in physical therapy and occupational therapy. Yoga improves proprioception, balance, strength, body awareness and mental focus. All of these things may be affected by a stroke.
One study investigated the personal experiences and perceived outcomes of a yoga program for stroke survivors using a qualitative research design. (13) Nine individuals who had experienced stroke were interviewed following a 10-week yoga program involving movement, breathing and meditation practices. An interpretative phenomenological approach was used to determine meanings attached to yoga participation as well as perceptions of outcomes. Perceived benefits were organized around bio-psychosocial themes of health benefits from yoga. Emergent themes from the analysis included: greater sensation; feeling calmer and becoming connected. These themes respectively revealed perceived physical improvements in terms of strength, range of movement or walking ability, an improved sense of calmness and the possibility for reconnecting and accepting a different body. The study generated original findings that suggest that from the perspective of people who have had a stroke yoga participation can provide a number of meaningful physical, psychological and social benefits and support the rationale for incorporating yoga and meditation-based practices into stroke rehabilitation programs. (13)

Lung Disorders
Chronic Obstructive Pulmonary Disease (COPD) makes it hard for you to breathe. Coughing up mucus is often the first sign of COPD. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath (dyspnea). Cigarette smoking is the most common cause of COPD. Breathing in other kinds of irritants, like pollution, dust or chemicals, may also cause or contribute to COPD. Quitting smoking is the best way to avoid developing COPD.
Chronic obstruction to gas exchange in the alveoli by mucous formed in response to irritants like cigarette smoke and air pollution.  It can lead to Chronic Obstructive Pulmonary Disease (COPD).  Most people with emphysema are 65 years of age and older and it affects about 2 million people in the US.  There is currently no cure for COPD; however, COPD is both a preventable and treatable disease.

Conventional Treatment for COPD
Smoking cessation is one of the most important factors in slowing down the progression of COPD. Air quality can be improved by pollution reduction efforts which should lead to health gains for people with COPD. Bronchodilators are medicines that relax smooth muscle around the airways, increasing the calibre of the airways and improving air flow. They can reduce the symptoms of shortness of breath, wheeze and exercise limitation, resulting in an improved quality of life for people with COPD. They do not slow down the rate of progression of the underlying disease. Bronchodilators are usually administered with an inhaler or via a nebulizer. Corticosteroids act to reduce the inflammation in the airways, in theory reducing lung damage and airway narrowing caused by inflammation. Supplemental oxygen can be given to people with COPD who have low oxygen levels in the body. Oxygen is provided from an oxygen cylinder or an oxygen concentrator and delivered to a person through tubing via a nasal cannula or oxygen mask. Supplemental oxygen does not greatly improve shortness of breath but can allow people with COPD and low oxygen levels to do more exercise and household activity. Pulmonary rehabilitation is a program of exercise, disease management and counselling coordinated to benefit the individual.

Yoga for Chronic Obstructive Pulmonary Disease
Yoga incorporates deep diaphragmatic breathing, which slows down the respiratory rate. Yoga movements and stretches mobilize the ribcage and breathing mechanism to optimize breathing. Several studies have evaluated yoga programs as complimentary alternative care for patients with COPD.

Researchers prospectively evaluated the effects of yoga training on the quality of life (QOL) and the parameters of lung function in patients with COPD.(14) Thirty-three patients with documented COPD, per Global Initiative for Obstructive Lung Disease criteria, were recruited. All patients received standard COPD care. The QOL was assessed by the St. George Respiratory questionnaire. Standard spirometry and maximum inspiratory (maximal inspiratory pressure) and expiratory pressure (maximal expiratory pressure) were measured. Patients were taught selected yoga exercises including breathing exercises, meditation, and yoga postures for 1 hour, three times per week for 6 weeks by a certified yoga therapist. The quality of life and lung function were again assessed at the end of 6 weeks. Twenty-two patients completed the study. Differences in pre-yoga versus post-yoga scores were evaluated using paired t-tests. Statistically significant improvements (P < 0.05) were observed for the St. George Respiratory questionnaire, vital capacity, maximal inspiratory pressure, and maximal expiratory pressure. Yoga when practiced by patients with COPD results in improvement in the QOL and lung function on a short-term basis. ( 14 )

Another study investigated the tolerability and effect of yoga breathing on ventilatory pattern and oxygenation in patients with chronic obstructive pulmonary disease (COPD). (15) Eleven patients with COPD, without previous yoga practice and taking only short-acting beta2-adrenergic blocking drugs were enrolled in this study. Ventilatory pattern and oxygen saturation were monitored during 30-minute spontaneous breathing at rest and during a 30-minute yoga lesson. During the yoga lesson, the patients were requested to mobilize in sequence the diaphragm, lower chest, and upper chest adopting a slower and deeper breathing. Researchers evaluated oxygen saturation, tidal volume, minute ventilation, respiratory rate, inspiratory time, total breath time, fractional inspiratory time, an index of thoracoabdominal coordination, and an index of rapid shallow breathing. Changes in dyspnea (difficulty breathing) during the yoga lesson were assessed with the Borg scale. During the yoga lesson, data showed the adoption of a deeper and slower breathing pattern and a significant improvement in oxygen saturation. All the participants reported to be comfortable during the yoga lesson, with no increase in dyspnea index.  Researchers concluded that short-term training in yoga is well tolerated and induces favorable respiratory changes in patients with COPD. (15)

Dyspnea, or shortness of breath, is a distressing and disabling symptom commonly experienced by people who suffer from chronic pulmonary disease. A recent review of prevalence studies documented that 90%–95% of patients with advanced chronic obstructive pulmonary disease (COPD) experience dyspnea.(16) Medical and pharmacologic treatments are of limited efficacy for the relief of dyspnea in people with advanced COPD. Therefore, patients must rely on their own self-care strategies to manage their dyspnea on a daily basis. Home walking and supervised endurance exercise are strategies that have been shown to reduce dyspnea intensity (DI) and dyspnea-related distress (DD).(17) Prompted by patients' preferences for participating in different types of exercise, one group of researchers questioned if yoga training could be suggested as an alternative mode of exercise. Their primary purpose was to evaluate a yoga program for its safety, feasibility, and efficacy for decreasing dyspnea intensity (DI) and dyspnea-related distress (DD) in older adults with COPD. This randomized pilot study compared the effects of a 12-week yoga training program with a self-help book control intervention in patients with COPD. Patients in the control group received an educational pamphlet, “Living with COPD” (Krames Patient Education, San Bruno, CA) and were offered the yoga program at the conclusion of the 12-week period. Primary and secondary outcomes were measured at baseline and at 12 weeks and safety and feasibility outcomes were measured at the end of each yoga session. Patients were offered a total of 24 1-hour yoga sessions that consisted of yogaasanas (poses) interspersed with visama vritti pranayama (timed breathing). A majority of patients (77%) reported that the yoga program was beneficial and that their expectations were met or exceeded. The most frequently reported benefits were learning a new strategy for managing dyspnea and increasing the ability to perform ADL. Other reported benefits included improved breathing techniques and bronchial drainage; improved postures, relaxation, and stress reduction; improved feelings of well-being; enjoyable social interactions; pain relief; and increased awareness of breathing. Although dyspnea intensity and pulmonary function did not change, the ability of these patients to walk longer without feeling as bothered by dyspnea may indicate an improvement in their perceived ability to control their dyspnea during exercise. There were no adverse clinical events associated with the yoga training. In conclusion, researchers found that this yoga program was safe, it improved functional performance and decreased dyspnea-related distress during exercise while not increasing pain or dyspnea.(18)

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