Role of Applied Physiology in Management of Muscular Dystrophy by Yoga and Meditation

Abstract

Muscular dystrophies are a group of neuromuscular disorders of genetic origin, Duchene muscular dystrophy being one of the severe forms with no predilection for any ethnicity. The progressive weakness and muscle degeneration culminate in cardiac, respiratory and orthopaedic complications, often accompanied with emotional and psychological involvement. Scope of the introduction of yoga exists at all stages of the disease as an adjunct therapy in prevention of complications, arrest/slowing of progression of the pathophysiology, improvement in the quality of life with better psychosocial adjustment. The science of yoga was developed in ancient India from Eastern Sankhya philosophy in an attempt at establishment of mind–body alignment towards an ideal, intact human physiology. Yoga involves implementation of lifestyle measures aimed at physical, and cognitive development, management of emotions and spiritual conflicts and practicing non-attachment to material and worldly pursuits. Beneficial effects were noted in psychosomatic diseases of non-communicable nature. Practice of yoga in the form of asana (postures), pranayama (breath work), sensory withdrawal (pratyahara), introspection (swadhaya), cultivation of social and individual restraints and practices (yama and niyama) and focused relaxation (dharana and dhyana) has exhibited beneficial physiological change regarding, immunological profile, cardiopulmonary exercise tolerance, posture and equilibrium, sensory acumen, neuromuscular coordination, muscle strength and cognition.

1. Introduction

Yoga is an ancient Indian technology lifestyle management developed, more than 5000 years ago. It is conglomeration of philosophy positive psychology, emotional intelligence, art and science, all rolled into one package. The science and art of ‘living life’ has roots in the Eastern Philosophy of Sankhya Yoga. The word yoga is derived from the Sanskrit word ‘Yuj’ which literally means ‘to yoke’ or ‘to unite’. The three meanings assigned to yoga by scholars are to bind, union and identification with the self and the divine leading to inner peace and freedom. The true perspective of the psychospiritual lifestyle of yoga is to alleviate pain and suffering [1]. Consistent practice of the system of physical postures (asana), breathing and mental training with Ayurveda (indigenous native healing practice of India) leads to a higher state of consciousness and awareness of the non-suffering nature of the soul. In the words of Yoga Scholar, George Feuerstein ‘yoga therapy is an attempt at integrating traditional yoga concepts and techniques with western medical and psychological knowledge [2]. Yoga therapy aims at alignment of mind and body with a sense of harmony with one’s own self and the universe. Practice of yoga therapy is advised in all chronic ailments either as a palliative measure or as complementary therapy [3]. Concept of koshas or layers of existence – five sheaths of physical layer, energy layer, mind, intellect and innermost bliss constituting of gross physical body, subtle body (mental, cognition and emotional and intellect, and innermost layer of the self or the soul) and energy vortices (chakras) are components of yoga and yoga therapy along with diet and nutrition [1]. Chakras are associated with glands and their secretions situated almost along the vertebral column in the midline, namely mooladhara at the base of the spine, swadhisthana, at the level of the genitalia (sacral), manipura or the solar plexus at the level of the navel, anahata chakra at the level of the heart, vishudhi chakra at front of neck, agna chakra in between the eyebrows and sahasrara chakra at the top of the head at the vertex. These are the place where overwhelming emotional feelings are expressed, such as butterflies in stomach, heartache, choking, etc. Yoga includes application of physical postures, breathing techniques, code of conduct, diet, cleansing and detoxifying techniques and deep relaxation techniques, all with total awareness.

Practice of physical posture (yogasanas) causes postural alignments, improves strength, neuromuscular coordination, endurance, balance and flexibility. The breath work (pranayama) is a set of breathing techniques that help to improve the lung capacity and oxygenation of the cells and opens up the chest cavity along with practice of appropriate yogasana. Moreover, the practice of conscious breathing patterns also leads to enhanced perception of body and mind with its thoughts and emotions. Therefore, combined with calming postures and gradual physical stretches (awareness of somatic sensations) with mindful meditation (awareness of thoughts and emotions), continual self-reflection and introspection), yoga transcends mundane life, with conscious inhibition of overthinking and selective and limited energy-consuming distractions. Thus consistent practice of yogic lifestyle with yogic diet and detoxification and purifying techniques increase resilience of the mental turbulence and clutter in the mind is reduced, thoughts are focused on self-care, compassion aimed at seeking harmony with universe and life in general. The autonomic nervous system regains its balance by stimulating the parasympathetic limb whereby relaxation occurs, thus promoting enhanced digestion, blood flow, respiration, regulation of emotion and thoughts [4].

Maharishi Patanjali, the founder of modern yoga describes ashtanga yoga with its eight limbs as a complete set of yogic practice. The eight limbs that were described by him are yama (moral code of conduct), niyamas (personal discipline), asana, pranayama, pratyahara (sensory withdrawal), dharana (one point focused concentration), dhyana (withdrawal from worldly attachments and a state of relaxed concentration on the object of dharana) and samadhi (state of no conflict, absolute acceptance and stilling of turbulence of mind, joy, bliss and freedom). Yama and niyamas are further classified into ahimsa (abstinence from violence), satya (adherence to truth), asteya (non-stealing), brahmacharyya (limitation of worldly attachments) and aparigraha (limitation of needs and wants) [5].

Since yoga is essentially a form of mind-body medicine, consistent and regular practice of yoga lends a positive and promotive outlook to health and life. And to achieve this, all eight limbs of yoga function synergistically to a great extent for a purposeful and meaningful life. Yoga has been classified as a complementary and alternative form of therapy by the National Institute of Health. Yoga therapy mainly relies on four significant principles namely, consideration of the human body as a holistic entity attuned to nature, respect and reverence for individual unique characteristics, healthcare beginning with self-care, compassion and empowerment and lastly cultivation of a positive, accommodating mindset with acceptance [6]. Yoga therapy is particularly appealing as it is devoid of any untoward side effects. Nevertheless, yoga therapy and techniques are best performed and mastered with expert instructors in the field.

2. Therapeutic benefits of yoga and mechanism of action

How does yoga work? Yoga philosophy is founded on self-regulation. Yoga practice functions as a skillset integrating higher and lower brain networks. Self-regulation includes self-monitoring, self-discipline and motivation towards the achievement of the desired goal.

As mentioned earlier, the main therapeutic benefit of yoga is attainment of tranquillity of mind coupled with experience of bliss and joy. A conflict-free mind and a fulfilling sense of well-being even in the face of an incapacitating ailment is what yoga aims for.

There is an increase in self-confidence and efficiency, attentiveness and lowered irritability.

There is also an enhancement of positive outlook, optimism and self-awareness and empowerment with improvement in quality of life.

Inhibition of posterior hypothalamus responsible for sympathetic drive is attenuated with complementary activation of parasympathetic response restoring adapting autonomic reflexes.

This also leads to decrease in anxiety level, heart rate, blood pressure and cardiac output.

Greater prefrontal activity with suppression of limbic subcortical nuclei as in amygdala is reflected by decrease in fear, anger, rage and aggressiveness. Cortical thickness is greater in practitioners of yoga and regular meditators [7].

Stimulation of dopaminergic connections and dopaminergic neurons activate the reward area leading to a sense of fulfilment, pleasure and joy. Mood elevation also follows increase in serotonin levels with concurrent decrease in the levels of monoamine oxidase levels (MAO) [6].

Reduction of aches and pains in muscles and joints reduce with continued practice of yoga as a result of loosening of joints which are exposed to the full range of movement. Blood flow to the joint, capsule, cartilage and muscle increases. Lymphatic circulation is also activated and so are the proprioceptors. Infect, many chronic orthopaedic conditions exhibit a considerable amount of pain reduction [6, 8]. Deep relaxation, gentle stretches, static or dynamic, conscious breathing, visualisation, self-awareness and meditation are techniques to reduce pain.

Blood flow increase with the daily repetitive muscle stretches across the joint and hence, the oxygenation of the tissue and rapid clearing of the metabolites. This leads to increased demand for haemoglobin formation for binding with oxygen and increases tidal volume. With the rapid flow, risk of heart attack and stroke also decreases [6]. Platelet reactivity along with nitrous oxide release potentiates hypocoagulability state following yoga practice. Fibrinogen levels are also found to be decreased and activated partial thromboplastin time and platelet aggregation time increased. Number of blood cells and platelets is also increased. Haemoglobin and haematocrit levels are also increased at the end of the training period [9].

Also, metabolic profile is improved following yoga training and practice. Insulin sensitivity increases, and there is a substantial increase in glucose tolerance and improved lipid profile. Reduced stress perception leads to reduced activation of sympathoadrenal system and HPA axis with resultant reduction in oxidative stress and improved endothelial functions [10].

Since the consistent practice of yogic techniques involve isometric contraction, it leads to increase in skeletal muscle strength of inspiratory and expiratory muscles. There occurs steady and progressive improvement in peak expiratory flow rate (PEFR) and forced expiratory volume FEV1 [11].

Inflammatory markers such as tumour necrosis factor alpha (TNF α) and interleukin 6 (IL-6) are markedly reduced in regular yoga practitioners, making them less prone to inflammatory diseases [12] as compared to age and anthropometric-matched non-practitioners of yoga. Similar observations were recorded in a study with 200 participants over a three-month study period of yoga exposure. Significant increase was observed in levels of anti-inflammatory IL-10 with concurrent decrease in proinflammatory IL-12 levels. Significant increase was observed in the levels of TNF-α, IFN-γ, IL-1β, IL-6 and IL-8 along with an increase in brain-derived nerve growth factor BDNF levels [13, 14].

3. Which type of yoga?

There are many formats of presentation in yoga based on the emphasis of techniques practised. They are karma yoga (emphasis on duty), bhakti yoga (emphasis on surrender and devotion), jnana yoga (knowledge-based), kriya yoga (based on energy modulation), tantra yoga (based on chanting of hymns and prayers) and Patanjali s yoga of eightfold aspects is called raja yoga (royal yoga), a complete package with physical, mental and spiritual aspects of wellbeing.

Hatha yoga refers to another format which emphasises more on the physical aspect, that is, practice of yogasanas and pranayama, cleansing and detoxifying processes. Cleansing and detoxifying consist of fasting and forced vomiting and should be practiced only under expert guidance, and not to be tried without proper evaluation.

Pranayama is made of two words, prana (breath) and ayama (stretching). Pranayama, therefore, consists of a set of breathwork where the pattern of breath (inhalation and exhalation) is stretched and lengthened to the practitioner’s capability. Few of the breath work also requires the breath to be held either after inhalation before expelling the air out or following exhalation or before taking the air in. This type of breath work with breath holding is called kumbhaka.

Based on the pattern of emphasis on the phase of respiration, few of the major pranayama are alternate nostril breathing (where inhalation occurs through the nostril through which air was expelled in the previous cycle), bhastrika with active and forceful inhalation and passive exhalation. Kapalbhati is another such technique where the emphasis is on exhalation (forceful and active). Though considered a type of pranayama, kapalbhati is a cleansing technique through breathwork.

Principles for yogasanas can be performed by anyone of any age of ethnicity and culture.

Any posture is an asana when the movements are synchronised with respiratory excursions. The objective of yoga is to cultivate awareness: awareness of the body, mind, emotions, thought, self (purpose and meaning), environment, awareness itself as well as unawareness – Swami Gitananda.

The principles to be followed in practice of yogasanas are

• The movements are slow and steady and focused attention is on the movement.

• Inhalation in each opening movement and exhalation on closing or constricting movement

• Postures must be carried out on both sides. Right-sided movement must be followed with left.

• Each posture is followed with a complementary posture using the opposite muscle group. For example, a forward bend must be followed by a backward bend.

• Yogasana can be done anywhere, in any posture, whether standing, sitting or lying down. Simple yogasanas are possible in wheelchair-bound patients also.

• There is no specific time for yoga. However, yogasanas and pranayamas are best done in the mornings. Meditation is done following the asana and before bedtime.

• There is no dosage or limit for yoga. It can be practiced any number of times up to the capacity and capabilities of the practitioner. Manipulation becomes easier gradually as one progresses through the practice.

Breath is the bridge between body and mind. Pranayama is best practiced early in the mornings, before meal and in open/well-ventilated space in a peaceful surrounding, better still in natural surroundings. Pranayamas are many types though anyone can practice; it is better to be selective according to the time of the day, season and environmental temperature and the affliction or dosha of the subject. Pranayamas are better practiced as standalone performance or after yogasanas. Pranayama or breath regulation practice consists of three steps usually

1. a slow deep inhalation (puraka),

2. long and complete exhalation (rechaka) and

3. kumbhaka which is breath retention, either between inhalation and exhalation (antarkumbhaka) or between exhalation and inhalation (bahirkumbhaka).

Some of the types of pranayamas, which could be beneficial in muscular dystrophy are:

1. The three-stage pranayama which is one of the basic types of pranayamas for practicing breath awareness and increasing the lung function, expansion of the chest cavity and opening of airways. In a comfortable position, normal breaths are taken for a couple of cycles and then with deep inhalation abdominal wall is pushed outwards. As the inhalation continues, chest is expanded onto the neck region and with raising of the clavicular region and lifting of the shoulders. The reverse occurs in exhalation, first lowering the shoulder and clavicles, followed by gradual expulsion of air from the chest and finally squeezing the abdominal wall to the navel. This is one cycle and such cycles are continued to the capacity and capability of the patient and gradually increased. Continued practice of this deergha pranayama with constant focused attention the breath also relaxes the mind and is very efficient in slowing thought trafficking.

2. Nadishodhana or channel cleaning pranayama is a type of alternate nostril breathing. Right nostril is closed with the right thumb and exhalation is performed through the left nostril following a normal breath. Air is inhaled through the left nostril. Thereafter, the left nostril is closed with the ring finger of the same hand while slowly releasing the thumb on the right nostril for exhalation to occur. The next breath is inhaled through the right nostril and exhaled through the left nostril by lifting the ring finger. This comprises one cycle. Three to six such cycles may be attempted as per the capacity and gradually the number of cycles may be increased. Focus and attention should be on the length of inhalation and exhalation with as less noisily as possible.

3. The nadi-shodhana pranayama may be accompanied by breath holding (retention) after complete inhalation with both nostrils closed when it is termed as anulom vilom, as the subject becomes more familiar with the breathing pattern.

4. Kapalbhati: forceful, active exhalation with pulling of the abdomen towards the navel.

5. Bhastrika: rapid and forceful inhalation and exhalation

Consistent and long-term practice of pranayama and breath regulation help to regulate the vital energies to bring about harmony in autonomic functions [15].

Other significant physiological parameters affected by pranayama are reduction in the heart rate and both systolic and diastolic blood pressure with the practice of slow breathing.

There exists demonstrable evidence of decreased perceived stress scale score with practice of both slow and rapid breathing patterns. Improvement in self-regulation, mood and positivity has been noted. With regular long-term practice of pranayama, enhancement of neurophysiological and psychological function including emotional regulation and processing of emotions ensues [16, 17]. Most often, yogasana, pranayama and meditation are practiced together in a single sitting, in the order of asana, pranayama and meditation. HPA axis and simultaneous activation of neurohumoral also adds to reduction of stress and anxiety and improved quality of sleep by regulating pineal gland function and secretion of melatonin [15].

4. Usefulness and relevance of yoga therapy in Duchene muscular dystrophy

Duchene muscular dystrophy is the most common and severe form of muscular dystrophy culminating in unfortunate premature fatality arising out of cardiorespiratory complications. Breathing exercises can improve the respiratory functions to a great extent.

Hath yoga practice with pranayama especially kapalbhati and yogic breathing can improve lung function as well as increase the strength of the muscles if expiration which is the earliest to be affected. Thus decreasing hospital admission rate and complications [18, 19].

Back pain, osteoarthritis and fibromyalgia also have shown decline in musculoskeletal disorders through gentle yogic postures [20]. Report of improved mobility, respiratory function and quality of life had been documented while on medication [21, 22].

Home-based yoga in Duchene muscular dystrophy has also showed improvement in heart rate variability. The children and parents were taught the exercises for a week. 124 DMD children were assessed in 5 years to 10 years, still ambulatory, with genetically confirmed DMD [23]. The protocol included the practice of gentle muscle stretches and breathing techniques along with other forms of physical therapy and another group with physical therapy alone. Parasympathetic trend showed a rising trend starting during the last 3 months of the study and remained stable for more than 1 year. Although the PT group too showed improvement, it was not long-lasting. Additionally, the children from 5 to 6 years demonstrated a significant earlier and sustained improvement. Strength and mobility were improved. Climbing activity was not much affected. With yoga, physical therapy provides a cardio-respiratory protective effect as well [24].

Studies done on palliative care showed improved quality of sleep, decrease in anxiety and overall improved quality of life with adequate stress management [24]. Emotional mastery and spirituality are two major fallouts achieved through regular practice of pranayama, which is immensely helpful in reducing the added anxiety and apprehension connected to clinical conditions as in Duchene muscular dystrophy imparting a great sense of control and autonomy over one’s own life. The reduced autonomic activity and parasympathetic dominant state help to achieve a calmer, peaceful state. These effects are mediated by either dopamine beta-hydroxylase, monoamine oxidase or adrenal steroids.

Yoga has the potential to be an excellent home-based adjunct therapy option offering holistic well-being. Not only muscle strength, flexibility, tone and endurance are increased but also provides emotional stability and positive attitude.

Breathing exercise or pranayamas with activation of muscles of respiration helps to increase the expansion of chest and lung function with considerable decrease in airway obstruction and clearing of the airways. This is well evidenced by electromyography studies that abdominal and oblique muscles are more effectively activated by yogic pranayamas than standard exercises.

Activation of expiratory muscles is much helpful for efficient aeration in patients of DMD.

Sarcopenia and loss of muscle mass are prevented and bone muscle density is also increased. Activities of daily living (ADL) have also been documented to improve. Manual muscle testing (MMT), records increased strength in distal, proximal and axial muscles following home-based yoga programme [25]. The reduction in catecholamine and angiotensin II levels, increased bioavailability of nitrous oxide go a long way to improving the circulation and perfusion of the muscles. In DMD along with anti-inflammatory actions of yoga (lowered IL-6 and C-reactive protein). It had been noticed that fibrosis was also reduced [25].

The programme is also beneficial in causing greater self-care and active interest, participation and involvement in daily activities. Chronic pain is reduced by improved aeration and perfusion, muscle atrophy is avoided causing improved motor function. Muscle strength and balance are certainly improved.

5. Conclusion

Effects of yogic practices have not been studied in much detail as in other non-communicable diseases including cancer of either genetic and hereditary or otherwise [26]. Yoga therapy is a science with a preventive, promotive, curative and palliative approach with not much preparation and precaution and teaches to embrace suffering for the upliftment of the soul [1]. Therefore, there is tremendous scope of application of yoga in afflictions such as in muscular dystrophy. Yoga is a useful tool for coping with stress for immediate caregivers also.

Studies and research on usefulness and implementation of yoga therapy in muscular dystrophies are very minimal, hence we have undertaken to propagate and promote the palliative aspect of yoga therapy.

Acknowledgments

To all my masters from who I learnt the philosophy and techniques of yoga, to the Divine to endow me with an opportunity to be introduced to yoga, to my colleagues and my students for providing opportunity to help propagate the philosophical science of Yoga by way of research and education. Life is a whirlpool of experiences. I owe my gratitude to all who have contributed to my journey into the yogic path, even in the smallest way. I bow in reverence to the guru and the master in all souls in the universe.