Role of Yoga and Spirituality in Stroke Rehabilitation

Abstract

In spite of the best treatment, 30–50% of stroke survivors are left with significant physical and/or psychological disabilities and consequent decline in quality of life (QOL). The silver lining is that up to 80% of stroke survivors can become independent in activities of daily living with adequate rehabilitation. Rehabilitation with physiotherapy, occupational therapy, and speech therapy offers a good opportunity to regain functional abilities. However, there is a shortage of neurorehabilitation (NR) programs across the globe, more so in resource-poor countries. The secular practice of yoga and spirituality is associated with a host of physical, physiological, cognitive, and psychological benefits that can be effectively included in stroke rehabilitation (SR). It has been shown to increase creativity and reduce stress as well as improve muscle power, dexterity, visual perception, and reaction time. These practices promote the positive effects on carotid atherosclerosis, hypertension, diabetes, and coronary artery disease, which are all identified risk factors associated with stroke occurrence or reoccurrence. Yoga and relevant practices are low cost and have good acceptance amongst patients and caregivers. In spite of yoga and meditation as useful tool, it has not been addressed adequately in stroke rehabilitation.

1. Introduction

Stroke is the leading cause of disability across the globe and with better care, more people are living following stroke with mild to severe neurologic deficits. This has a negative impact on both psychological and physical health and quality of life [1]. The majority of such patients reach the plateau of their recovery within 6 months [2]. It has been observed that a good and sustainable rehabilitation program can result in improvement in muscle power, balance, mobility, risk of fall, and aerobic capacity in up to 70% of the poststroke patients [3]. Rehabilitation in stroke focuses on the recovery of function and cognition to the maximum level achievable and may include a wide range of complementary strategies including yoga [4]. The rehabilitation of stroke is a multidisciplinary process involving physicians or stroke specialists, nurses, physiotherapists, psychologists, nutritionists, occupational therapists, speech therapists, and audiologists [5, 6]. These patients require long-term rehabilitation and because of the high cost and lack of qualified therapists, they are not able to avail them. Thus, there is a strong need for novel strategies, which are low cost, suitable for home care, particularly in rural areas, and address the physical and mental needs of the patients and caregivers [7]. Yoga and meditation are such tools that are being explored in the last two decades or more. However, it is yet to find widespread acceptance. This review aims to update and synthesized the role of yoga and meditation intervention in stroke rehabilitation (SR).

2. Stroke rehabilitation

The primary purpose of rehabilitation is to maintain or improve an individual’s functioning and independence. Neurorehabilitation (NR) services are essential to optimize physical, psychological, and cognitive functioning of patients with compromised neuropsychological functions especially in the initial 3–6 months poststroke [8]. There are marked inconsistencies in quality of care and rehabilitation services across the globe. Such services are needed both during the acute stage and during later phase of disease [9, 10]. NR with conventional physiotherapy, occupational therapy, and speech therapy offers them a good opportunity to regain QOL and activities of daily livings (ADLs). However, it is mostly underutilized and major barriers are limited availability, geographical distance, high cost, and lack of awareness about its benefits [8, 11, 12].

SR is a multidisciplinary process involving doctors, nurses, physiotherapists, occupational therapists, neuropsychologists, linguistic and speech specialists, audiologists, and nutritionists [13]. It is not a “one size fits all” intervention and a combination of interventions suits better to treat motor and sensory impairments, cognitive deficits, and psychological issues. Physical therapy in form of active and passive joint movement, muscle strengthening, and gait training was the cornerstone of SR till the recent past. Newer techniques such as repetitive task training (RTT), constraint-induced movement therapy (CIMT), mirror therapy, use of botulinum toxin to relieve spasticity, advanced gait training with robotic-assisted therapy and virtual reality, electrical stimulation (ES), noninvasive brain stimulation (NIBS), cognitive rehabilitation, and neurofeedback are newer addition to the armamentarium [6].

While use of technology (e.g., virtual medical examination, tele-counseling, robotic-based and exoskeleton interventions, and telerehabilitation) to manage NR has the potential to reach a large number of patients even in remote areas with limited physical contact, they have the disadvantage of complexity and high cost [8]. In this situation, yoga and spirituality as an adjunct to conventional physical and psychosocial aspects of rehabilitation merit a serious consideration [6]. Subsequent discussion in this article will focus on spirituality and yoga as an adjunct in SR.

3. Spirituality and yoga

Ancient spirituality and related practices, not synonyms with religion, are widely used for prevention of diseases, promotion of health, and as possible treatment modality for neurological and psychiatric disorders [14]. These practices include prayer, yoga, meditation, dietary modification, and mental remodeling. Recently, we are discovering their health benefits and are finding a bigger role in the field of rehabilitation [15]. They are cost-effective and self-administered options with advantages of their use in both urban and rural areas with minimal physical interactions. Spirituality and yoga, though interconnected, are different as explained below.

3.1 Spirituality

Spiritual technologies are not new to us and are guiding us through ancient times. There is no agreed definition of the term spirituality. It is a blend of humanistic psychology with an individual relationship with higher powers and the subjective experience of the “deepest values and meanings by which people live” [16, 17, 18].

To have wider application, it is necessary to distinguish spirituality from religion. While spirituality refers to a quest in life or a transcendent relationship with a higher power, religion focuses on community-based doctrine, prescribed beliefs, practices, and rituals [6, 17, 18]. Spirituality is generally considered to be a much broader construct than religious faith, although the two concepts may overlap [19]. It must be clarified that being spiritual does not necessarily mean religious, whereas the reverse is true.

As such studies relating to spirituality and rehabilitation for neurological illnesses are limited, much research is needed to evaluate their specific role [1, 17]. Though higher levels of spirituality are known to be associated with a better quality of life (QOL) for people with neurodisability and their caregivers, most of the medical staff are not well equipped to administer it [20, 21].

3.2 Yoga and meditation

Yoga is a way of life and an ancient mind-body practice that originated in India more than 5,000 years ago. It is now recognized worldwide to have spiritual, physical, and mental health benefits [1, 22, 23]. The word “yoga” is derived from Sanskrit verb “yuj” meaning to yoke or unite. Commonly, yoga is translated to imply the union of body, mind, and spirit [22, 24]. Meditation in its many forms has been practiced over millions of years by diverse groups of people in many different traditions. In a more modern context, it can be defined as “a systematic practice and implementation of mind and body in the living process of human beings to keep harmony within self, within society, and with nature” [25].

There are many practices of yoga and they include varying combinations of spiritual way of life, different bodily postures (asanas), controlled breathing (pranayam), physical and mental relaxation, contemplation, control of thoughts and mind (concentration meditation), and open-mindedness or mindfulness [1, 14, 22]. Meditation, the most important component of yoga, aims at giving peace to the mind and increasing awareness of environment and higher consciousness.

The practices of yoga and meditation strengthen willpower and control of mind and body to work in perfect synergy [1, 13]. They are known to promote cardio-respiratory and metabolic health (reduction of carotid atherosclerosis, dyslipidemia, hypertension, diabetes, and coronary artery disease) and as a possible treatment modality for a variety of neurological and psychosomatic disorders [1, 22, 26].

4. Mechanism of improvement in stroke with yoga

Though yoga and spiritual techniques-based practices are becoming increasingly popular in the management of many physical and psychological illnesses, the neurobiological effects of such practices in improvement are not well understood [4, 27, 28]. It must be appreciated that unlike majority of conventional SR techniques aims at deficit recovery (external mechanism), spirituality and yoga work at intrinsic recovery of the brain as well. Neuropsychological studies have shown that mindfulness meditation training improves immunity, cognitive skills (thinking, reasoning, judgment, and memory), attention-related behavioral responses and emotional liability, and reduction in autonomic arousal [1, 27].

4.1 Autonomic nervous system

There is increasing support for the theory that relates the positive effects of yoga to a close link between the central nervous system and the autonomic nervous system, along with the endocrine and immune systems. It is believed that yoga techniques favor a down-regulation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS), leading to a prevalence of the parasympathetic nervous system over the SNS, possibly through direct vagal stimulation [4]. Moreover, breathing control and meditation practices in yoga increase the autonomic control, and reduce blood pressure, heart rate, and breathing. These changes may help in poststroke rehabilitation through restoration of physical and mental health, promotion and coordination of complex movements, balance, strengthening, and breathing.

4.2 Hormonal changes

The stress hormones (such as cortisol) that compromise the immune system can be balanced through practice of yoga [29]. The practice of yoga enhances the activity of many hormones connected with mental health such as melatonin and gamma aminobutyric acid (GABA) [30, 31].

There are pieces of evidence that meditation-based training increases many growth factors such as brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF), glial-derived thrombospondin 1 and 2, and growth-inducing proteins (neuromodulin, CAP23, MARCKS) [32]. Higher levels of these growth factors are associated with better neuroplasticity, neuronal morphology (synaptic and dendritic changes), and cortical reorganization improving functional outcomes following neurological illnesses.

4.3 Brain structures

Till recently, it was believed neural tissues do not regenerate. Now, we have learned that it is possible to reconstruct neural circuits with transplanted endogenous neural stem cells or through mental training such as meditation [33, 34]. Long practice with yoga has been associated with changing brain structures with an increase in gray matter density in structures involving memory, attention, self-awareness, compassion, and control of the autonomic nervous system [27, 33]. Functional magnetic resonance imaging (fMRI) studies have shown increased gray matter in the hippocampus, prefrontal cortex, cingulate cortex, and brain networks including the default mode network (DMN) [1, 26, 27, 35]. In contrast to this, there was a decrease in the grey matter in the amygdala, the part of the brain associated with fear and stress.

4.4 Epigenetic

Epigenetic refers to a way to regulate gene activity in real time without modifying the DNA sequence. It allows the body to function in changing environment. Yoga and related practices have been shown to alter gene expression, particularly those related to free radical handling, inflammation processes, mitochondrial energy production and utilization, and apoptosis [1, 36, 37].

4.5 Cellular oxygenation and general well being

As a result of practice of asanas (body posture), pranayam (control of breathing), and control of thoughts and mind, there is general improvement in well-being and a positive outlook in life. With respiratory practice (pranayam), there is improvement in the lung capacity and respiratory health, which in turn improves supply of the oxygenated blood to multiple organs for smooth optimal function [30].

4.6 Dietary modifications

Lifestyle diseases such as obesity, accelerated atherosclerosis, insulin resistance, type 2 diabetes, and cardiovascular disease are major risk factor contributors to occurrence of stroke [38]. They are targets in both primary and secondary preventions of the stroke. Current dietary practice is loaded with a high proportion of refined carbohydrates and saturated fats. Thus, it is logical to build body-mind through diet, exercise, healthy lifestyle choices, and mental remodeling with spirituality. Spirituality and meditation techniques mandate a vegetarian diet rich in fiber content and unsaturated fats with less refined carbohydrates (Table 1).

Restructuring dietary intake and fasting Be vegetarian and avoid nonvegetarian meals Plenty of fluids Avoid junk food Avoid night meals and follow intermittent fasting (with a feeding and fasting schedule of 8:16 hours) Adequate intake of proteins, vitamins, minerals

Table 1.

Some simple dietary principles with spiritual technologies.

5. Yoga and spirituality for stroke rehabilitation

Spirituality, meditation, and mind-body exercises are novel therapeutic approaches in improving neurological outcomes and enhancing cognitive capabilities [13, 39, 40]. Such practices allow SR in less complex and highly individualized environment. However, yoga and meditation programs should be tailored to deliver personalized interventions according to each person’s profile and rehabilitation needs. Being a low-cost model, it improves availability of rehabilitation in low- to middle-income countries. Though it is effective and less labor intensive, there is a lack of evidence-based review to support the claim.

Few specific practices of meditation that have been used for stroke rehabilitation are Preksha Meditation (based on perception theory), Qigong (Chinese body-mind exercise), and yoga-based asanas or exercises [11, 19, 39, 24, 32, 41, 42, 43, 44, 45]. A recent systematic review concluded that yoga can be used as self-administered practice in stroke rehabilitation, due to its effect on relieving the mind and body from stress. Yoga was found to act at both psychological and physical levels, and improvements were noted in self-efficacy and confidence [1, 4].

5.1 Motor and sensory functions

Rehabilitation in ICU & During acute phase: Patients with moderate-to-severe stroke are often subjected to prolonged bed rest and mechanical ventilation [13]. Such patients have a significant deficit of motor functions in form of profound muscle weakness, fatigue, diffuse myalgia, balance deficits, fear of falling (FoF), dysautonomia, orthostatic hypotension, respiratory muscle weakness, deep vein thrombosis, decubitus ulcer, joint contracture, and impaired ADLs. Neuromotor rehabilitation is a key concept of recovery from immobilization syndrome. Modified yoga (a combination of postures, breathing, and meditation) has been shown to improve vital capacity, muscle power, range of movements, walking capacity and speed, self-efficacy, and improved quality of life [11, 22, 41, 43, 46].

Rehabilitation during subacute and chronic phase: Several investigators have found improvements in muscle force, balance, aerobic capacity, timed mobility, and aphasia in subjects with chronic poststroke hemiparesis following yogic interventions [24, 39, 42]. Bastille and Gill-Body [41] demonstrated that yoga results in significant improvement in muscle power and range of movements in hemiplegic limbs and some positive effects on the Berg Balance Scale (BBS), Timed Movement Battery (TMB), and quality of life (QOL) as assessed with Stroke Impact Scale (SIS). Schmid et al. [11] in a study of 37 poststroke patients managed with yoga interventions observed significant improvement in balance (Berg Balance Scale, 41.3±11.7 vs. 46.3±9.1; P<0.001) and fear of fall (51% vs. 46%; P < 0.001). In a study carried out by Singh et al. [43], Preksha Meditation training was given to 22 subjects with hemiplegia and was compared with an equal number of controls at 3 months. A significant improvement was observed in muscle power and range of movements in hemiplegic limbs. In another prospective trial, Qigong practice for 16 weeks in stroke subjects was associated with improvement in balance capacity, physical well-being, and psychological well-being [44]. Psychological improvement with reduction in anxiety and depression and better QOL are additional advantages of mediation, which is helpful for patients and their caregivers [21, 22, 23, 42, 47]. Wang et al. [45] in a systemic analysis of 33 rt-fMRI neurofeedback studies on 651 healthy individuals and 15 stroke patients observed a learned modulation of brain signals, with associated changes at both the neural and the behavioral levels with this intervention.

Thus, meditation and mind-body exercises are a novel therapeutic approaches to enhance cognitive capabilities and are effective in improving poststroke outcomes [11, 21, 22, 26, 39, 40].

5.2 Cognitive rehabilitation

A large number of patients with stroke suffer from cognitive impairment. There are many types of cognitive deficits in these patients, which include forgetfulness, confusion, disorientation, problems with attention, executive functioning, information processing, etc. [48, 49]. However, cognitive rehabilitation is still far from satisfaction. Meditation and other mind-body interventions are effective in improving cognitive functions in these patients [50, 51]. However, only a small number of stroke patients have been evaluated with yoga-based interventions and Mindfulness-Based Stress Reduction (MBSR) programs in subjects with cognitive impairment. There is a requirement to study a larger number of patients and to design modified yoga program to suit different characteristics of stroke patients.

5.3 Stress and psychological

Apart from motor deficits, stroke patients have a significant cognitive deficit, stress, negative emotions, frustration, boredom, disturbed sleep, anxiety, losing a job, financial problems, depression, and behavior-related problems that hamper their recovery [8, 52]. These emotional stress results not only in de novo illnesses but can exacerbate preexisting illnesses as well. Some simple tips are given in Table 2 and the list can be expanded with personal experience.

It is pertinent for us to identify stressors early and manage them accordingly. Few simple steps are; Be friends with all livings beings Prefer positivity over negativity Gratitude to those who help Strengthen emotional bonding Watch & learn from kids & nature Be environment friendly Be happy in small acts Good sleep

Table 2.

Simple mental remodeling steps.

Spiritual techniques and yoga provide a good non-pharmacological approach to handling such psychological issues that are common among patients and caregivers [1, 22, 25, 49, 53]. Yoga has been demonstrated to provide relief from stressful psychological states with a reduction in anxiety, depression, and cortisol levels. Immink et al. [42] observed significant improvements in quality of life associated with a perceived motor function (P = .0001), perceived recovery (P = .072), and memory-related quality of life scores (P = .022), with decreases in state and trait anxiety following yoga intervention. In a recent cross-sectional, online survey of clinicians (n >600) regarding coping strategies employed by them to mitigate stress was physical activity/exercise (59%), psychotherapy (26%), yoga (25%), religious or spiritual practices (23%), meditation (23%), and virtual support groups (16%) [54].

5.4 Caregivers

Developing a caregiver-driven stroke rehabilitation program has been attractive in India to address the scarcity of rehabilitation centers and trained therapists. The physical and mental health of caregivers is an important consideration in long-term SR. Spirituality and resilience needs of caregivers must be strengthened so that they can cope with the burden [8, 19].

6. Modification of yoga practices for stroke rehabilitation

While motor deficit and spasticity management in SR are well organized, the mental health program is not standardized and there is a requirement to develop a holistic module considering all aspects of rehabilitation. Spirituality and yoga are cost-effective self-administered options for SR and should find a place in the SR schedule [1, 6]. It is recommended that these interventions should be tailored to deliver personalized interventions according to each person’s profile and rehabilitation needs (duration of illness and level of impairment, function and mobility, etc.).

Some of the asanas suggested are downward-facing dog, tree pose, and child pose, and these can restore balance and significantly reduce the risk of falling for stroke patients. In view of physical limitations, practice of asanas should have provision for adequate support such as practice against the wall, use of head gears, etc. A suggested module as designed by the author is given in Table 3 and should be modified as per patient’s need.

Step description	Duration
1. Place, position, and prayer (decided on patient’s condition and disablement); Select a quiet place with least distraction. Comfortably sitting on a chair or lying in the bed. Prayer: Content is left to person’s belief and faith. It will be either a silent one by the self or play a recorded one.	5 minutes
2. Posture (asanas) and loosening movements: Based on patient’s condition movements can be active, passive, or assisted. Based on physical disablement, one can increase it to 10−15 minutes	10–15 minutes
3. Pranayam (breathing exercises) and controlled breathing: Make breathing slow, long and rhythmic. Take a deep breath in with your mouth closed and hold it comfortably for 2−4 seconds. Then exhale effortlessly with mouth closed. Repeat this initially for 5 times in 2 minutes and with practice gradually increased it to 9−11 times in 7−10 min. Pranayam has shown to enhance body oxygen utilization, improve concentration, and clean the respiratory passages.	7–10 minutes
4. Body relaxation with awareness (Kayotsarga); Instruct body to relax each part, one by one, from the toe to the upper part of the head. Autosuggest for relaxation of muscles, body, and mind. Maintain this relaxation of body and mind initially for five minutes and with practice increase it to ten minutes.	10 minutes
5. Concentration meditation; With eyes closed focus your attention on a single object, idea, sensation, or aspect of divinity (e.g., counting or monitoring breathing, reciting a mantra, visualizing processes in the body, external object, etc.) at the exclusion of all other thoughts. Distracting thoughts will invariably appear but try to ignore them by focusing the mind through autosuggestions.	7–10 minutes
6. Open mindedness; This is a higher stage of meditation, which can be practiced after one has mastered concentration meditation. Instead of focusing attention, there is expansion of awareness and attention. All sensory inputs, be it internal (thoughts, feelings, memory, etc.) or be it external (sound, smell, etc.), are perceived as they are without any prejudice and in a nonreactive way. This provides a stimulus to gain access to knowledge, self-realization, and soul (consciousness) purification.	7–10 minutes
7. Conclusion; Gently close your meditation session with producing mahapran dhavani on two occasions. Rub your hands and move your body freely.	One minute

Table 3.

Stroke rehabilitation module with spiritual and yoga practices (To be under guidance of a physician & trained yoga teacher).

7. Future

There is a good potential for spiritual technologies to be included in the NR schedule. Some of the areas that need to be considered for research are as follows:

1. Research-based modification of yoga and meditation schedule to suit disabilities, limitations, and co-morbid conditions.

2. To quantify benefits and acceptability of these technologies in a large number of people.

3. To elucidate neurobiological mechanism of these technologies in bringing the improvement.

4. To develop and amalgamate delivery of these procedures with use of low-cost technologies such as smartphones or tablets for tele-counseling, tele-training, tele-monitoring, and tele-rehabilitation.

5. To develop guidelines for use of spiritual technologies and yoga in SR.

8. Conclusions

The field of stroke rehabilitation has a bright future. In spite of good potential for recovery, these rehabilitative measures are underutilized and major barriers are limited availability, geographical distance, high cost, and lack of awareness about its benefits. Scientific evidence indicates that yoga may constitute a promising add-on therapy for a number of diseases. It is a simple to learn, adaptable and community-based practice, which could be cost-effective [1, 4]. Studies relating to spirituality and rehabilitation for neurodisability including stroke are limited [16, 17]. They can be employed at a hospital, home, and workplaces alike. Recent experiments have proved its benefit in achieving physical, mental, and spiritual health. Medical and paramedical practitioners involved in SR should be aware of them and educate the patients and caregivers.

Meditation is a body-mind exercise that could be a cost-effective and useful technique for poststroke rehabilitation [21, 23]. Though spiritual techniques are effective and less labor intensive, there is a lack of evidence-based review to support the claim. Such interventions should be considering variables such as duration of illness, type and level of impairment, and functional need. However, large-scale methodologically robust trials are required to study mobility, balance, postural stability, coordination, cognitive changes, and QOL [4]. It is recommended that yoga and meditation interventions should be designed to meet patients’ different characteristics (time after stroke, level of impairment, function, and mobility). To maintain the continuum for stroke care and reduce morbidity and mortality with stroke, there is a need for public health systems in both developed and developing countries to improve stroke awareness and to implement proper strategies of triage, acute treatment, well-defined rehabilitation plans, and teleservices [8].

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

Nil.

Author contributions

This review was prepared by the sole author (PS).

Abbreviation

QOL	Quality of life
NR	Neurorehabilitation
SR	Stroke rehabilitation