A brief introduction to working with clients who have chronic but stable conditions.
Mindful exercise programs—particularly yoga, qigong and tai chi—have played an increasing role in managing a number of chronic-disease states in recent years. The most prevalent chronic illnesses in the United States are cardiovascular disease (primarily heart disease and stroke), cancer, diabetes and arthritis. Medical-care costs of treating chronic conditions account for more than 75% of the $2 trillion spent annually on medical care (CDC 2008).
By providing mindful exercise programs, wellness professionals can offer vital help in managing several chronic- disease states. “Mindful exercise” here denotes low- to moderate-level physical exercise coupled with a significant meditative/contemplative and breath work component. In reviewing the benefits and risks associated with mindful modalities, this discussion will consider three diseases in particular—cardiovascular disease (CVD), diabetes and hypertension; if pulmonary diseases are not counted, these three represent about 60% of all chronic disease in the U.S. (CDC 2007).
Quality research on mindful exercise and chronic disease is progressing slowly—most studies published to date have used small subject numbers, been statistically underpowered and/or suffered from inadequate controls. However, there is scientific evidence that hypertension, insulin resistance, anxiety disorders, pain, CVD risk factors and depression all respond favorably to regular participation in mindful exercise modalities, particularly tai chi, qigong and hatha yoga (see the sidebar “Research-Supported Benefits of Hatha Yoga and Tai Chi”).
Mindful activities that are helpful for clients with stable chronic disease share these characteristics:
- They can be taught at relatively low intensity levels (e.g., 2–4 METs) and can be individualized.
- They decrease real-time cognitive arousal (i.e., they calm the mind) and stress hormone activation.
- They enhance proprioception (muscle sense) and kinesthesis.
- They improve muscular strength, posture and balance.
- They improve self-efficacy and confidence.
When selecting mindful exercise programs for clients with chronic disease, follow these two key guidelines:
- Always choose a modality that can be performed with very low physical effort (e.g., 2–3 METs) in the beginning and then graduated slowly in terms of difficulty and intensity of effort.
- Work only with clients whose disease course is stable (i.e., who have no unstable symptoms).
In general, mind-body teaching guidelines are very similar for CVD, diabetes and hypertension.
Be Schooled in the Fundamentals. If you aspire to work with clients who have chronic conditions, be sure you know and can follow current pre-exercise assessment and exercise training guidelines for those with medical conditions (ACSM 2006, AACVPR 2004). See the reference list for details.
Begin Gently. With clients who have stable CVD, type 2 diabetes or stage 1 hypertension (systolic blood pressure 140–160 millimeters of mercury, or mm Hg), begin with low-level (2- to 4-MET) mindful exercise forms that do not generate large and rapid increases in heart rate and blood pressure. Tai chi chuan, tai chi chih, restorative yoga and viniyoga are examples of suitable lower-level programs.
Progress Very Gradually. Bear in mind that energy expenditure costs relate directly to cardiorespiratory costs. Therefore, be very judicious in graduating the energy cost of the exercise, not only from session to session but also within each session. Having a working knowledge of the energy cost (caloric or oxygen cost) of each segment of a session is a key skill that is worth acquiring. The sidebar “Approximate Energy Costs of Select Mindful Exercise Modalities” shows three levels of energy expenditure by MET level, along with associated mindful exercise modalities. This list is based not on actual comparative energy expenditure studies but on approximate values taken from overall movement dynamics and case studies. Individual cardiovascular and musculoskeletal health, style proficiency and familiarity, and body mass all play roles in the energy expenditure and cardiorespiratory requirements of each form.
While hatha yoga offers many benefits for people with chronic disease, it is important to observe the following precautions:
Use Caution With Those Who Have Documented Coronary Heart Disease. Since many styles of hatha yoga involve acute dynamic changes in body position, the hemodynamic (blood flow) and cardiac ventricular responses to such exercise may alter cardiac function in clients with CVD—including those with hypertension or diabetes. This is because rapid changes in head-trunk-heart position can quickly change filling pressures in the heart’s ventricles, placing significant stress on a heart if it is already compromised. For clients who have recently (within 2 months) had a heart attack or who have heart failure, this means avoiding inverted yoga poses, in which the head is below the heart (for example, downward-facing dog and headstand), as well as vinyasas that alternate an inverted pose with a head-up pose—at least in the beginning stages of a program. With these clients, it is essential (1) to minimize acute, rapid changes in body position (changes in limb and trunk position in relation to the heart—i.e., no inverted poses) in early training and/or (2) to transition more slowly from one yoga pose to the next.
Avoid Rapid Changes in Blood Pressure. Some yoga poses can cause significant and rapid changes in blood pressure. These poses may be inappropriate for clients with stage 2 or higher hypertension (i.e., those with blood pressures ≥ 160/105 mmHg). DiCarlo and coworkers (1995) demonstrated significantly greater systolic and diastolic blood pressures in subjects practicing Iyengar yoga compared with those doing moderate treadmill walking (~4 miles per hour). This, however, does not contraindicate Iyengar yoga for reasonably conditioned adults with stable CVD.
Carefully Match Programs to Clients’ Ability Levels. Ashtanga, Iyengar and Bikram yoga asanas and sequences require considerable muscular strength and mental concentration; thus, they may be more appropriate for individuals with higher levels of function (e.g., those whose exercise capacity exceeds 11 METs).
Of all the characteristics of mindful exercise programs, the breath work component may be the most beneficial, particularly for patients with CVD, hypertension or diabetes. One key reason why yogic breathing can be therapeutic is that controlled, systematic, intentional inhalations and exhalations can induce temporary relaxation responses by stimulating the parasympathetic pulmonary neural receptors (see Figure 1). In a helpful review of yogic breathing techniques, Sovik (2005) described optimal yogic breathing as diaphragmatic, nasal (both inhalation and exhalation), deep, smooth, even, quiet and free of pauses.
In addition to reducing stress and mental tension, yogic breathing yields immediate cardiac benefits. In 10 subjects who had frequent premature ventricular contractions (PVCs—i.e., extra heart beats originating in the ventricles of the heart), Prakash (2005) demonstrated a 50% reduction in PVCs after controlled deep yogic breathing at six breaths per minute. When skillfully taught, yogic breathing can even reduce the emotional-cognitive triggers for acute coronary syndromes (ACS)—i.e., heart attacks or acute chest pain episodes—in patients who have coronary disease and are vulnerable to cholesterol plaque rupture.
If you would like to introduce clients to yogic breathing, note the following:
Defer to an Experienced Instructor. It is strongly recommended that clients initially learn the techniques from an experienced yoga breathing instructor. If you do not have experience in this area, refer your clients to someone who does.
Be Cautious With Beginner Yogic Breathers. When practiced by itself, yogic breathing is a very powerful exercise. Many people—but especially those with CVD or pulmonary disease—can experience dizziness or loose consciousness while performing beginning or advanced techniques. Some techniques—for example, breath retentions and breath suspensions—should be used with caution. Breath retentions are brief pauses (2–5+ seconds) taken at the end of controlled inhalations. Breath suspensions are similar-length pauses taken at the end of controlled expirations. While very brief pauses (2–3 seconds) appear to be relatively safe, those with CVD, hypertension, obstructive pulmonary disease or asthma should avoid retentions or suspensions longer than 4–5 seconds and should focus instead on the standard breath work taught in most yoga programs.
Mindful exercise continues to emerge as an effective exercise modality and nonpharmacologic approach to treating a variety of chronic diseases. The core benefits include increased balance, strength and flexibility, as well as immediate improvement in relaxation and mental quiescence. Regular, self-regulated mindful exercise may also be ideal because of its individuality, portability and relatively low intensity. It is not beyond reason that in the near future, respected clinical exercise consensus publications will include mindful exercise guidelines for primary and secondary prevention of chronic diseases.