Breathless and associated anxiety is common in patients with advanced illness and is a major cause of hospital admissions at the end of life (1,2).
Patients and their carers are – understandably – fearful of this debilitating and complex symptom for which pharmacological options are limited.
Not being able to breathe is a primal, life-threatening sensation, and quality of life is severely reduced in those living with this often under-assessed and under-treated symptom, whatever their disease (3).
Like pain, breathlessness is a subjective experience and, similarly, breathlessness has affective and sensory dimensions (4). People with advanced disease experiencing refractory breathlessness may suffer from anxiety, panic attacks, fatigue, depression, cognitive difficulties/confusion, hopelessness and isolation (5).
Carers (who are often older and unwell themselves) are negatively affected; oxygen cylinders and masks need to go everywhere, acute attacks are frightening and impossible to manage, cognitive changes and physical dependency all take their toll and close relationships and carer health can suffer (6).
What is mindful yoga?
Yoga is an ancient practice originating over 3,000 years ago from north-west India (now in Pakistan) aiming to “quiet the fluctuations of the mind.” (Patanjali)
Mindfulness is a secularised practice with its roots in Buddhism and is described by its founder Jon Kabbat-Zinn as “paying attention in a particular way, on purpose, in the present moment, and non-judgementally.”
Both practises develop awareness of, and concentration, on the breath, with yoga specifically offering a huge variety of postures and movements directed towards manipulating the breath and improving respiratory function.
Both practices have a core focus on acceptance and compassion; the aim is not self-improvement but rather self-acceptance and ‘kindness to self’. For many of us this is an entirely new way of thinking, living as we do in an intensely competitive culture where being ill can feel like a kind of failure, rather than an inevitable part of life’s journey.
The ancient yogis discovered that regulating the breath affects the limbic system (the part of the brain responsible for the ‘fight-flight’ response) thus calming an agitated mind and improving mental focus. Neuro-imaging techniques have recently supported their experience – regulating the breath and mindfulness meditation do reduce anxiety and affect the brain mechanisms involved in regulating emotion and concentration (7,8).
Mindful yoga in the hospice
When I’m running small groups in the day hospice, or using these techniques one-to-one on the ward, the first step is to help patients to understand the way the breath affects the mind and visa-versa; why the breathing problems make them feel so anxious, or why feeling so anxious makes the breathing worse and how the resulting downward spiral works.
Psycho-education of this sort has a theoretical basis in cognitive behavioural therapy and, in combination with an explanation of the brain/body feedback loop, helps breathless patients to understand what is happening, what won’t happen (sudden death from air hunger) and how they can regulate and manage better for themselves.
Mindful yoga then offers a simple, practical way to develop awareness of breathing and thinking that is non-judgemental and compassionate, and this I believe to be a key process.
Negative internal voices (“I caused this by smoking” or “I’ve just got to get on top of this”) are replaced by kind and positive affirmations (“I let go”, “I forgive” or “I relax my breath”).
Awareness of held body positions and muscles (tight shoulders, collapsed chest) is cultivated and reversed and simple exercises, suitable for even the most disabled patient are taught and practised each week in order to release and strengthen primary and secondary respiratory muscles.
Time is spent together in the group practising slow, regulated breathing (or pranayama) and there is always time for silent meditation and guided relaxation.
The group is extremely supportive and this element is crucial; the “held” space of the mindful yoga group is very different to the “social” space of day hospice and boundaries of confidentiality and mutual support are agreed and respected.
What do patients say about Mindful Yoga?
I have been running a mindful yoga group at Sobell House, Oxford for nearly five years. Along with pain, breathlessness is one of the most troublesome physical symptoms for the patients I have met there, with anxiety (affecting sleep, quality of life, relationships etc) the predominant psychological symptom.
Patients using an anonymous questionnaire evaluating the service made the following comments:
- “The yoga gives me something I can do. I feel in charge of my body.”
- “I feel relaxed and I used to panic about things.”
- “I feel confident to do without my oxygen much more.”
- “My pain levels are less random and more predictable giving me better coping ability… overall a huge improvement in living with pain.”
- “I enjoy being aware of others in the same boat, and doing things together.”
These comments reveal positive outcomes in physical, psychological and social domains from attendance at the mindful yoga group just once a week.
The focus in service provision for palliative care is increasingly towards early intervention and rehabilitation for all patients with advanced illness. Helping people to reduce disability, maximise independence and coping skills and to live well is cost effective, reduces hospital admissions and decreases dependency on carers.
Mindful yoga may be an effective approach to incorporate into hospice care, but high quality evidence is needed.
I am currently in the final months of an MSc in Palliative Care at King’s College London and my dissertation is on yoga, pain and palliative care. I am systematically reviewing the literature on effectiveness and hope to develop the evidence-base for yoga in palliative care with further research.
Training day at Sobell House, Oxford on 16 October 2015
Using breathing, relaxation and mindful awareness are useful in a myriad of ways for any clinician or therapist working in palliative care and can be incorporated into the patient/carer/clinician relationship.
To find out more about the evidence-base for mindful yoga, learn specific techniques for working with breathlessness, anxiety and pain – and to incorporate these into your own self-care and build personal resilience – come along to our training day on 16 October.
- Blackmore S, Iles M, Verne J. Deaths from respiratory diseases: implications for end of life care in England. National End of Life Care Intelligence Network; 2011. Available from: http://www.endoflifecare-intelligence.org.uk
- Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. Journal of Pain and Symptom Management. 2006; 31(1):58-69. doi:10.1016/j.jpainsymman.2005.06.007.
- Gysels MH, Higginson IJ. The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND. BMC Palliative Care. 2011; 10:15. doi:10.1186/1472-684X-10-15.
- Booth S, Chin C, Spathis A. The brain and breathlessness: understanding and disseminating a palliative care approach. Palliative Medicine. 2015; 29(5):396-98. doi:10.1177/0269216315579836.
- Bailey PH. The dyspnea-anxiety-dyspnea cycle – COPD patients’ stories of breathlessness: ‘It’s scary /when you can’t breathe’. Qualitative Health Research. 2004; 14(6):760-78. doi:10.1177/1049732304265973.
- Miravitlles M et al. Caregivers’ burden in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease. 2015; 10:347-56. doi:10.2147/COPD.S76091.
- Streeter CC et al. Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study. Journal of Alternative and Complementary Medicine. 2010; 16(11):1145-52. doi:10.1089/acm.2010.0007.
- Marchand WR. Neural mechanisms of mindfulness and meditation: evidence from neuroimaging studies. World Journal of Radiology. 2014; 6(7):471-79. doi:10.4329/wjr.v6.i7.471.