Chronic Fatigue & Meditation and Mindfulness for Long Covid populations
Best Practice from Chronic Fatigue Syndrome Research
Existing evidence demonstrating the benefits of yoga practice and protocols for Chronic Fatigue assists us in exploring the potential therapeutic benefits of yoga as a healthcare intervention for individuals experiencing symptoms of Long Covid.
The medical advice given during the C19 outbreak was that it was a ‘mild’ disease, with most people recovering in 1-2 weeks (NIHR, 2020). This messaging potentially affected people’s ability to listen to their own body’s signals and take adequate deep rest. Despite the misconception that powering through or engaging in progressive exercise can assist Fatigue, the new NICE guidelines recommend ‘paced’ exercise as opposed to graded. ME Advocates urge people with Long Covid to learn from experiences of CFS, stressing the importance of listening to your body, and balancing physical and mental activity with rest rather than pushing yourself to boost stamina.
Normally a dynamic yoga-asana practice can be used to reduce ANS reactivity by increasing HRV via lifting and lowering of the system. However, in cases of persistent fatigue where individuals are ‘tired but wired’ dynamic uplifting asana may cause over-exertion and breathlessness. A gentler restorative-based practice focussed on simple joint release and movement with breath may be more effective. The vast majority of asana research for fatigue focusses on isometric exercise, however, experienced Yoga Therapists are encouraging working on an individual basis with mindful somatic movement (Agombar, 2020) undulations and joint release (Rothenberg, 2020) which are less exerting, and focus on healing via the breath (Verma, 2020).
Asana should focus on movements that encourage diaphragmatic release such as supported twists and gentle side bends, alongside poses that increase vagal tone to support parasympathetic response. Prone asana is beneficial for breathless populations as it releases tension in the diaphragm, and allows space for the lungs to work more efficiently thus increasing oxygenation (Henderson et al. 2014). Clinical application of prone position has been shown to improve patient survival in moderate to severe ARDS (Setten et al., 2016) and according to recent research, studies suggest prone positioning in ‘awake, spontaneously breathing patients is practical outside of ICU environments’ as a means of improving oxygenation (Sztajnbok et al., 2020). Examples are supported crocodile or seated supported forward fold positions and taking savanasa in supported crocodile can be beneficial.
NICE guidelines suggesting gradual exercise, emphasise and perpetuate ‘doing’ rather than ‘being’. Yoga offers a route into ‘being’ via mindfulness practices and meditation. Alongside yoga asana and daily pranayama practice to calm a chronic stress response, meditation has also been shown to be capable of significantly increasing vagal tone and downregulating the stress response in the body effective against inflammatory based disease as well as reducing stress and anxiety (Boyd, Lanius and McKinnon, 2018).
Mindfulness based practices & Meditation
Mindfulness based practices can be helpful on many levels to sufferers of persistent fatigue, having the capacity to work with both the physical and psychological challenges faced. Oka et al. (2018) investigated ongoing symptoms of CFS via an 8-week seated isometric practice and reduced fatigue and increased energy was reported after a single session. Changes in blood biomarkers suggest that anti-stress and anti-inflammatory effects were observed including decreased heart rate, decreased levels of TNFa, reduced cortisol levels and increased DHEA (Dehydropepiandrosterone), decreased levels of which can increase feelings of fatigue and cognitive impairment.
Given the psychosocial stressors faced by individuals with Long Covid symptoms, loving kindness or compassion-based meditations may help reduce feelings of fear and foster a deeper connection to ourselves and to others. Just as certain forms of stress can synergize to produce greater negative consequences, the converse can be true for ‘metta’ meditations, potentially leading to a ‘broadening and building’ of social connectedness through generation of positive psychologic states (Hutcherson, Seppala and Gross, 2008).
Meditation is capable of significantly increasing vagal tone and could therefore be effective against stress, trauma, and inflammatory based diseases via reduction of proinflammatory cytokine production (Bushell et al, 2020). Dutcher et al., (2020) demonstrate that 6 weeks of 20 min daily mindfulness meditation resulted in significant downregulation of TNFa and cytokine IL-6, which is linked to SARS-CoV-2. Some of the cytokine-related effects of meditation practices are related to downregulation of the sympathetic nervous system, as evidenced in parallel reductions in epinephrine and norepinephrine.
A randomised controlled trial examining mindfulness meditation in comparison to exercise for preventing acute respiratory infection found that meditation and exercise were both beneficial and both demonstrated reasonably strong data supporting their capacities to alleviate stress, anxiety, depression and pain (Spijkerman, Pots, Bohlmeijer., 2016), but meditation evoked a larger reduction in global acute respiratory infection severity compared to exercise (Barrett et al. 2012).
According to a small but relevant body of research, compelling studies show that regular practice of meditation is associated with elevations in melatonin (Nagendra et al., 2012). As elevated levels of cortisol reduce production of melatonin this could be of particular benefit for Long Covid. Solberg et al. (2004) reported experienced meditators has 150% higher resting levels of melatonin than the comparison group matched by age, gender and physical fitness. In addition to assisting sleep, melatonin has beneficial effects on mitochondria and possesses significant antiviral properties with particular relevance to respiratory diseases (Bushell, W et al. 2020).
The kosha model, made up of five layers, allows us to address individuals as more than just body and mind. By addressing the appropriate ‘layer’, Yoga Therapy can provide subtle and appropriate practices that build upon each other to create balance in each layer. This system is especially beneficial in addressing Long-Covid ‘sickness behaviour patterns’, such as inadequate nutrition and poor sleep habits, which further weaken an already compromised immune system.
Sleep loss has been shown to elevate inflammatory cytokines (Mullington, Simpson, Meier-Ewert and Haack, 2010) therefore, yoga and meditation practices to promote healthy sleep may be beneficial to reduce inflammation and affect overall sense of wellbeing. Via the annamaya kosha, we can address tension in the body via physical yoga practices to support sleep by calming the body (Sanfilippo, 2019) and via the third layer, manomaya kosha, we can explore mindfulness practices to alleviate anxiety, and promote a more restful sleep.
For those experiencing breathlessness and pain, the kosha model can be an effective method of linking the socio-emotional with the physical, and Jon-Kabat-Zinn (Harvard Health, 2016) recommends body scans to encourage tracking of sensation from annamaya kosha, with the aim of inviting investigation of pain in order to learn from it. This can be especially useful for Long Covid by empowering individuals to practice healthier responses to physical sensations
Yoga Nidra, is a systematic meditation technique, inducing conscious physical, emotional and mental relaxation (Singh and Singh, 2010). Sometimes called yogic sleep, Yoga Nidra is thought to balance pranic energy through the nadis and has been demonstrated to be an effective way to induce deep physiological rest and relaxation. The state of yoga nidra represents a conscious entry into a state of non-REM sleep (Parker, Bharati and Fernandez, 2013) thought to create the optimal environment for healing via the art of non-doing (Desai, 2017).
ECG imaging studies have suggested that during Nidra, blood-flow is reduced to areas of executive functioning such as the Pre-Frontal Cortex, in addition to areas related to sensory processing such as thalamus and cerebellum (Kjaer et al., 2002). For those experiencing anxiety and increased sympathetic activation this could be particularly beneficial. A Randomised Controlled Trial demonstrated significant decreased anxiety following Yoga Nidra (Srivastava et al., 2011) and results showed significant improvements in positive wellbeing, general health and vitality. This could be especially useful for Long Covid populations in need of deep rest.
However, due to the paradox of being ‘wired but tired’, sympathetic activation is often prominent and although the individual may be exhausted, they are unable to relax without movement to release cortisol allowing them to access the parasympathetic state more easily. A process of gentle movement prior to Nidra can be useful for Long Covid populations suffering persistent fatigue, and Yoga Therapist, Helen Moss, has created a specific method ‘Nidra Restore’ which weaves the narrative of Nidra into 3-4 restorative postures making deep relaxation more accessible.
From my own experience of fatigue and Long Covid symptoms, I have found that working from a nervous system regulatory perspective has been most beneficial. Breathing practices have been my priority, specifically coherent breathing alongside gentle restorative based mindful movement and Yoga Nidra meditation. Whilst working with Long Covid individuals, I have encountered, a ‘desperation’ to feel better, alongside fear, anxiety and depression. Managing levels of expectation has been paramount and working towards a ‘new normal’ via the release of old habits, and behaviours that consume much needed energy, is a vital part of the process in empowering each person towards a greater sense of wellbeing. Grounding practices and working gently, whilst encouraging self-compassion, allows for energy levels to replenish naturally.
As an emerging profession focussed on health promotion and wellbeing, Yoga Therapy is well-suited to working with Long Covid individuals. Yoga Therapy’s collaborative approach to working facilitates self-healing from an individualised perspective, encouraging and empowering those suffering with multiple symptoms towards a place of deeper self-awareness and compassion beyond the diagnosis. Yoga is not a panacea, however, research indicates that the therapeutic application of yoga for populations experiencing respiratory issues, fatigue and dysregulated nervous systems, could be an effective approach to address the parallel pandemic.