According to World Health Organization's Palliative Care Fact sheet 2015, each year, an estimated 40 million people need palliative care and 78% of them live in low- and middle-income countries.1 From a global perspective, there is a need to develop effective and economically feasible palliative care strategies to address the needs of the population suffering from serious illness and improve their quality of life. Originated in India more than 5000 years ago, yoga is a mind body practice which aims to create harmony and balance of physical, mental, and spiritual aspects of life.
Although yoga is being practiced since ancient time, yoga as therapy is still a relatively new and emerging trend in the healthcare field. A growing body of research on yoga for palliative care has shown improvements in the sleep quality, mood, stress, management of physical symptoms, and overall quality of life.2, 3, 4 Palliative potential of home-based yoga sessions in women with advanced cancer was evaluated in a study.2 Enhanced mind-body and body-spirit connections, benefits at physical, mental, and emotional level as well as the alleviation of illness impacts were observed.2
Meditation and pranayama, along with the relaxing yoga poses, can help in dealing with the emotional aspects of chronic pain, reduce anxiety and depression effectively, and improve the quality of life.5 There is a substantial evidence suggesting the efficacy of yoga practices in reducing the impact of exaggerated stress responses and coping with anxiety and depression. It mainly acts via downregulating the hypothalamic pituitary adrenal (HPA) axis and the sympathetic nervous system.6
In recent years, many studies demonstrated that mindfulness (a ‘relaxed wakefulness’ practice based on the ancient eastern tradition of meditation) reduces pain. ‘Mindful yoga’ was suggested to be a feasible and acceptable approach for pain, fatigue, sleep disturbance, psychological distress, and functional impairment in women with metastatic breast cancer.7 It is believed that mindfulness meditation engages multiple unique brain mechanisms and psychological mechanisms by which a yoga intervention attenuates the subjective experience of pain. Relaxation postures and yoga nidra have been found to reduce analgesic requirements and improve sleep and reduce fatigue in malignant pain states.5
The emotion-regulation through present moment awareness, acceptance, and non-reactivity in mindfulness practices has the potential to enhance the quality of life and overcome fear of death. The relevance of the yoga sutra of Patanjali in end-of-life yoga care was explored by Taylor.3
Patanjali yoga sutra describes ‘abhinivesha,’ Sanskrit word meaning ‘will to live’ or ‘clinging to life’. Fear of death is present in all aspects of human consciousness because of powerful attachments (raga) to objects of joy.
Yoga practice is a complex intervention with varied components. Many different styles of yoga differ in approach and techniques. However, yoga practices can be adapted to the individual needs and can be performed by persons having functional limitations. Yoga therapy for palliative care is based on gentleness and compassion. It aims to empower the patient to accept and face the illness and death by holistic experience which has physical, mental, emotional, and spiritual dimensions.
The following are the examples of some yoga practices useful in palliative care.
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Gentle yoga poses (asanas):
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Supported and modified stretching is recommended to suit individual needs. Restorative yoga consisting conventional poses with props facilitates stretching, provides support and induces relaxation.5 Asana reduces fatigue and pain in patients with cancer.8
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Regulated breathing techniques (pranayama):
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Diaphragmatic breathing effectively reduces the anxiety level9 through the reduced sympathetic activity and enhanced vagal activity. This can be practiced by anyone, regardless of age or physical condition and anywhere, even in a hospital bed.
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Deep yogic breathing with prolonged exhalation relaxes most skeletal muscles and help to cope with stress and anxiety.5
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Gestures (mudra):
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Balancing, calming mudra (subtle physical movements) provide comfort and are easy to perform by anyone. Taylor3 suggested a few possibilities like anjali mudra, vajrapradama mudra, padma mudra, and adhi mudra for end-of-life yoga therapy.
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Meditation (dhyan):
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‘Internalized awareness’, the peculiar feature of meditation, facilitates coping with stress.5 Faith healing through spiritual means may be effective complementary therapies for pain and symptom's relief in palliative care.
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Yoga Nidra (conscious, dynamic, yogic sleep):
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It provides complete relaxation, peace, self-awareness, and self-efficacy and reduces rage, anxiety, and emotional reactivity.10
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Nada Yoga (chanting mantra or singing):
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It reduces anxiety11 and positively increases the EEG Alpha and general well-being.
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Mindfulness:
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This can be practiced anytime, anywhere, and suitable for even the most disabled patient. It is suggested that mindfulness-based practice can assist traumatized individuals in coping with the stresses encountered and assist them in facing the realities of sickness, pain and death.
A thorough evaluation of the patient's condition ensures a tailor-made yoga program to compliment individual health status and avoid adverse effects. A relatively safe yoga style to suit the individual requirement under the guidance of a qualified yoga professional is recommended. The practices are modified for unique circumstances, of even bedridden or chair-bound individuals and the participants are encouraged to work at an individual pace-within oneself's physical capacity. In advanced metastatic cancers with bone involvement, poses which stresses the bones are to be avoided. Hyperventilation practices such as kapalabhati (forceful exhalation and automatic inhalation) and bhastrika (bellows breath) may result in the risk of causing pneumothorax in patients receiving radiation for lung lesions and they are contraindicated.12
What yoga can offer in palliative care is a holistic approach in which the ‘individual’ as a whole is focused on, not just the disease. It includes a patient-centered wider perspective of wellness with the aim to offer relief from symptoms, pain, physical difficulties, mental stress of illness, and improved quality of life. The side effects are minimal when yoga is practiced under guidance. Yoga can be practiced at any age and can be performed almost anywhere, even on the hospital bed. It is said that, “If you can breathe, you can do yoga.”
Lack of awareness in the health professionals and the general population about the benefits of yoga for palliative care is a challenge. There are some misconceptions prevalent about yoga that it is just an exercise to be performed by flexible people. Cultural and social barriers about yoga may also be a concern in adopting yoga practice. There is a need to create awareness in the population as well as healthcare professionals about the benefits of yoga in symptom management and dealing with psychological and spiritual needs.
Integrating ancient wisdom of yoga and spirituality in the conventional palliative care setting appears to be a promising, cost-effective, and time-honored holistic approach offering a comprehensive wellness plan for patients.
Conflict of interest
The author declares no conflict of interest.
References
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