Yoga Therapy for Long Covid
There is an urgent need to identify effective approaches and treatments for the multiple symptoms of Long Covid. Covid-19, as an acute condition associated with multiple chronic comorbidities, has propelled a shift in research focussed towards investigating the role of the host in the disease process resulting in renewed interest in therapies derived from integrative and complementary medicine (Bushell et al., 2020). Research focussed on the benefits of yoga for Long Covid is scant but emerging research is compelling in supporting yoga practices as a beneficial adjunctive in the healing and relief of the symptoms of Covid and Long Covid sequalae (Nagarathna, R et al. 2020).
Working from the biopsychosocial model, Yoga Therapy perceives disease to be an interaction between the biological, psychological and social. Gabor Maté MD defines this as ‘a perpetual interchange of energy in which the psychological and social factors are as vital as physical ones’ (Maté,2019. p243). Yoga therapy, as an individualized holistic approach takes into account not only the patient’s mind, body and spirit, but also their family, support network, work situation, and culture, as part of the patient’s individualized treatment plan (Stephens, 2017). This supports the use of Yoga Therapy as a potential personalised approach to facilitate wellness in Long Covid populations.
Allopathic medicine works from a diagnosis-driven model, whereas Yoga Therapy facilitates a collaborative process between client and therapist, to explore new ways of meeting thoughts, feelings and sensations in the body. From the yogic perspective the concept of connection and safety are essential to alleviate suffering and this is particularly relevant for individuals post-Covid, who may be experiencing symptoms of PTSD, and anxiety in addition to feeling judged and misunderstood (Outhoff, 2020). Stephen Porges’ Polyvagal Theory (1994), emphasises the need for creation of safe space in the context of how treatment is delivered in order to down-regulate the nervous system: “The real issue in therapeutic relationships is whether the individual is safe in the presence of the other”. Yoga Therapy, based on Rogerian therapeutic qualities of empathy, congruence and unconditional positive regard (Rogers, 1959) is particularly well-suited for delivery of a holistic treatment plan, and therefore establishment of a positive therapeutic alliance with a Yoga Therapist could be an effective part of the healing process for Long Covid populations.
Since the symptom sequalae of Long Covid is complex and multi-factored, flexibility in approach is vital and we may encounter overlap in the many appropriate access points available to treat multiple symptoms. The main symptoms I will focus on are Post-Covid respiratory issues, persistent fatigue and dysregulation of the nervous system causing chronic stress. Based on current evidence, some suggested approaches are as follows:
Encouraging optimal breathing and increasing oxygenation
As coronavirus is a predominantly a respiratory based virus, it is vital that pranayama is an important focus of any Yoga Therapy treatment plan, not only to counteract feelings of breathlessness and increase oxygenation to the body, but also because the breath affects the whole-body system. In Yoga Therapy we can capitalise on the relationship of the breath to physiological functioning and in its ability to alter psychological state.
Breathing, as the only autonomic function that can be voluntarily controlled, provides a portal through which selected breathing patterns can be utilised to send messages through the nervous system and interoceptive system to affect how the brain perceives, interprets and responds to stress (Streeter et al., 2007). When breathing is slow and controlled the thalamus releases high levels of GABA, the major inhibitory neurotransmitter of the brain associated with calming the nervous system. Low levels of GABA are correlated to most mental health issues (Petty, 1995). Yoga Therapy can provide tools and techniques that can be a source of empowerment for individuals experiencing anxiety and breathlessness.
Using an approach of working with the breath to balance the nervous system is key to alleviating breathlessness, improving lung function and increasing oxygenation for Long Covid populations. The average person breathes erratically, accessing only 10% of their available diaphragmatic range, delivering just enough gaseous exchange for survival but not enough to thrive or feel energised. Cellular respiration must be optimised for populations experiencing depleted energy levels and breathlessness. Breathless populations often breathe more rapidly in the misguided perception that it will deliver more oxygen, in fact it does the opposite (Rothenberg, 2020). Gentle diaphragmatic breathing should be encouraged to promote a fuller breath increasing oxygenation saturation in the blood-rich lower part of the lungs (Mason, The Minded Institute M2 p.129) slowing the heart rate and calming the system by activating the parasympathetic nervous system due to vagal nerve innervation around the diaphragm.
Diaphragmatic breathing can be encouraged by crossing arms over the chest which has the effect of restricting upper chest movement (Mason, Minded Institute M2 p.125). In addition, we can use the placement of the hands on the shoulder as a sensory feedback reminder to keep the shoulders relaxed and low. This form of breathing has the additional benefit of acting like a self-hug. Research demonstrates that even hugging ourselves releases oxytocin, which is found to play an important role in stress regulation by lowering norepinephrine levels and reducing blood pressure and heart rate (Olff, M. et al. 2013).
Changing the pattern or rhythm of the breath has a rapid effect on brain activity improving sympatho-vagal balance and promoting stress resilience (Brown & Gerbarg, 2012). Coherent Breathing brings the body into an optimum state of maximum functioning by reducing the breath rate to 5 or 6 breaths per minute. This even ratio of inhale and exhale improves biomarkers of mental and physical health and may be especially beneficial for Long Covid populations as it reduces activation of the respiratory chemoreflex, down regulates sympathetic drive and enhances parasympathetic response (Bernardi, 2002).
Gerbarg & Brown have had years of experience using coherent breathing with trauma survivors. Following 9/11 and after two-months of daily practice, the lungs of survivors displaying ground glass opacity were clearing (Brown & Gerbarg, 2012, p.71). Findings suggest that the benefits of coherent breathing practice for trauma-survivors have many advantages translatable for use with Long Covid populations:
- Accessible to different cultures
- No equipment is required
- Cost-effective once training complete
- Easy to learn and easy to teach
- Highly sustainable as an ongoing long-term treatment plan.
Breathing practices can create a ‘community resiliency’ (Brown & Gerbarg, 2012, p.84) which is especially relevant in terms of Yoga Therapy for Long Covid populations who often feel socially isolated and misunderstood. The potential of large-scale and individualised programs could assist in creating a sangha, or community of support for those experiencing long-term respiratory issues.
The objective of breath practices for Long Covid is to regenerate the pranic body, therefore gentle breathing practices are advised as opposed to pranayama that may irritate already damaged airways (Rothenberg, 2020). Oxygen levels can be further enhanced via nasal breathing, due to the reduction in respiratory rate and the effects of filtering, warming and moistening the air for optimal absorption by the lungs. Nasal breathing adds 50% more resistance to air flow via the inhale (Gilbert, 1999), increasing pressure in the lungs which results in a 10-20% increase in oxygenation (Cottle 1987). Research on specific pranayama for Covid-19 supports Nadi Shodhana Pranayama, or Alternate Nostril Breathing, demonstrating its potential to be less exerting (reducing Rate of Perceived Exertion), whilst simultaneously improving parasympathetic activity (Shukla, M et al. 2020).
Nasal breathing has specific advantages for Long Covid populations due to its calming effect on the mind and body and the increased production of Nitric Oxide (NO). Known as endothelium-derived relaxing factor (Ignarro et al., 1987), NO plays a key role in physiological regulation of the cardiovascular system. NO is biosynthesized endogenously and released when we breathe through the nose, providing medical benefits of being anti-bacterial, anti-microbial and importantly, anti-viral. It improves the ventilation-perfusion ratio in the lungs which increases oxygen uptake, and acts as a vasodilator of the smooth muscle of the airways, making it easier to breathe (Taneja, 2020). Further research demonstrates that NO is the only substance so far to have a direct effect on SARS CoV2 (Akaberi et al., 2020) and so for those experiencing breathlessness post-Covid, nasal breathing should be the predominant breathing practice.
The addition of humming via modified ‘brahmari’ pranayama whilst nasal breathing, has been demonstrated to further increase the production of nitric oxide 15-fold (Taneja, 2020). Enhancing expression of NO via humming, is a consequence of oscillating sound waves affecting air exchange in the sinuses. Similar to ujjayi breathing, the noise that we create whilst humming may also act as an anchor for the mind, reducing ruminations. It has been suggested that during Om chanting, the hum vibrates the auricular vagus, stimulating the parasympathetic system further adding to the calming effect. Our respiratory rhythm directly and indirectly affects the Central Nervous System affecting our state of mind and ‘brahmari’, a playful and uplifting breath, can bring joy to fatigue sufferers. (Mason, M2 p.242).