by Dr Vikas Chothe & Dr Shwetambari Chothe

MD, PhD Ayurveda Sch, FIIM, Yoga Ambassador, Lead Yoga
Examiner and Assessment Expert YCB, Ministry of AYUSH
MD Homoeopath, Consultant Yoga Therapist, Founder and Director of Swasti Yoga Center

Yoga for Post-Operative Patients
by Dr Vikas Chothe & Dr Shwetambari Chothe MD, PhD Ayurveda Sch, FIIM, Yoga Ambassador, Lead Yoga Examiner and Assessment Expert YCB, Ministry of AYUSH MD Homoeopath, Consultant Yoga Therapist, Founder and Director of Swasti Yoga Center

Yoga is an ancient tradition coming from the root word Yuj meaning union with universal consciousness of individual consciousness or one-pointed awareness. In the Yoga sutras of Patanjali the first sutra is Atha yoga anushasanam, which means “yoga” is a form of discipline. This also reflects that without a disciplined lifestyle learning yoga is not possible as without a disciplined healthy lifestyle complete health (swasthya) is non existential. The word “anushasan” can be broken down into two parts: “anu” meaning “the subtle aspects of human personality,” and “shasan” meaning to “rule over” or to “govern”.

Though the culture of popping pill for every ill has rose in recent decades with leaps of modern medicine and advances in surgery, recurrences and complications are evident in those postoperative patients who have a poor unhealthy lifestyle. Therefore, the concept of yogic discipline is knowledge of the subtle dimensions, the aspects of human personality and directing or governing the subtle nature. In the absence of this discipline there will always be a search to find happiness and harmony, a persistent sense of emptiness inside, and a feeling of not fulfilling or deriving the best from life.

Role of Yoga:

No surgeon can entirely erase the post-operative pain, so know that coping with some pain is part of the healing process. Yoga practices foster willpower, discipline, and self-control and force the mind and body to work in perfect synergy for the recovering patients. Therefore, many studies have found that mindful yoga practices have beneficial effects as a stand-alone treatment on stress reduction and overall wellbeing. Yoga is emerging as a useful rehabilitation and cost-effective tool for various chronic lifestyle related ailments Intensive yoga-based life style modification program have been shown to retard coronary atherosclerosis and has been incorporated in life style interventions in CAD since nineteen seventies.

Meditation, an integral component of antaranga yoga increases the membrane potential of neurons and other body cells and reduce the activity of amygdala and cortical areas. Psychological health disturbed in post-surgery can be revived when combined with counselling sessions and meditation techniques of Yoga.

Many research studies have found significant evidence in using yoga as a treatment module in postsurgical patients including lung cancer. Out of 32 active smokers affected by lung cancer pre- and post-lung cancer surgery were benefited with yogic breathing practices of pranayama compared to only physiotherapy group. Pulmonary and cardiocirculatory functions were tested using a selfcalibrating computerized spirometer and a portable pulse oximetry device. The findings demonstrate appreciable short-term improvement in lung function assessed by spirometry. So, we can conclude that yoga breathing can be a beneficial preoperative support for thoracic surgery. Breathing exercises appear to help combat cigarette cravings too. Yoga exercise benefits have been studied in lung cancer survivors, rather than in the preoperative setting4.

Yoga for post CABG patients:

World Health Organization (WHO) has been sounding an alarm on the rapidly rising burden of cardio-vascular disorders for the past 15 years. The reported prevalence of coronary artery disease (CAD) in adult surveys has risen 4-fold over the last 40 years (to a present level of around 10%) accounting for 29% of all deaths in 20055 CABG alone can improve QOL much after 12 months, but there is still the necessity of multidisciplinary rehabilitation which focuses on emotional support, information about progression, patient education and peer education. A well-structured, multicomponent cardiac rehabilitation is associated with reduced mortality after CABG. There is a lot of importance for cardiac rehabilitation at the national and international level to reduce rehospitalization.

Depression and anxiety are cardiac risk factors are less but continue to be sustained even after 7 days, 10 days and after 5 years of CABG. Type D personality of CAD patients gave evidence that the physiological hyper reactivity and activation of pro inflammatory cytokines may be responsible for detrimental effects on cardiac prognosis. Yoga being a mind–body practice, it reduces anxiety, depression and blood pressure and also improves physical fitness as part of QOL. Integrating concepts of Yoga, Ayurveda, modern rehabilitation, surgery and patient cooperation with lifestyle change are the key to QOL improvements after CABG. Yoga combines physical, mental, social, environmental and spiritual practices and hence it should be added as treatment along with surgery and physiotherapy rehabilitation.

Secondary preventions such as risk factor management and initiation of rehabilitation are essential components for postoperative CABG patients to optimize graft patency and to achieve the highest level of physical health and QOL. Post CABG with regular practice of yoga and introduction to yoga philosophy will help in reducing the risk factors of addiction to smoking, alcohol and fried unhealthy eating habits. It will introduce good sleep pattern, healthy eating habits and balanced work life skills helping patients manage stress and enjoy life to its best. Research has shown that Yoga based
cardiac rehabilitation can improve the positive effect, skills of managing anxiety and depression than physiotherapy-based rehabilitation alone after 1 year of CABG

Research has shown that Yoga based cardiac rehabilitation improves ejection fraction and lipid profile after 1 year of CABG Yoga techniques meets the requirements of the constitution of WHO because it has many benefits such as increasing muscular strength and flexibility; promoting improvements in respiratory and cardiovascular function; promoting recovery from addiction; reducing stress, anxiety, depression, and chronic pain; improving sleep patterns and enhancing overall well being and QOL. Yogic Cardiac rehabilitation can also improve social functioning through return to work after 1 year of CABG by introducing yama (social restraints) and niyamas (personal restraints).
Faith is an independent and complex factor, influence the end life decision making ability which needs much medical attention for CABG patients. Philosophical concepts like Ishwar pranidhan (surrender to divinity), karma yoga (duty without desire for fruits of action) and abhyas vairagya (detached efforts) create a motivational drive in patient helping in defining life goals for future. Karma yoga from Bhagavad-Gita that helps in working without stress; Bhakti yoga, the path of pure love that opens up avenues for healthy relationships; and Jnana yoga that transforms the basic notions about life through introspective correction of the meaning and purpose of life.

The Pranayama practices of Yoga are meant to modulate breath capacity and increase the expected lifespan by increasing oxygen consumption and help in reduction of stress through parasympathetic dominance in post-surgical patients
Precaution: Though yoga is helpful in post CABG patients, specific practices, like Iyengar Yoga, reduce cardiac reactivity with intentional stress, which is the risk factor for cardiac disease and improve QOL

Model Yoga Based Cardiac Rehabilitation Program

Single blind prospective randomized parallel two armed active control study, for male patients posted for CABG at Narayana Hrudayalaya Institute of Cardiac Sciences, Bengaluru (India) with yoga based cardiac rehabilitation program and only physiotherapy based program

Yoga practice time duration under supervision: 1 hour/ day

Content for Pre-op day to 6 weeks for CABG patients:

1- Deep Relaxation Technique (DRT)
2- Mind sound resonance technique (MSRT)
3- Nadisuddhi Pranayama

MSRT is a systematic training consisting of 8 steps of sound meditation (based on Mandukya Upanishad and Gheranda Samhita) It involves gentle chanting of the syllables A, U, M, and OM to feel the resonance inside the body cavities i.e. abdomen, chest, skull and entire trunk respectively. This is done repeatedly while alternating between audible chanting (Ahata Nadanusandhana) and mental chanting (Anahata Nadanusandhana). This phase is followed by a resolve and closing prayer.
Results of the Narayana Hrudayalaya Institute of Cardiac Sciences, Bangalore study:

Results of the Narayana Hrudayalaya Institute of Cardiac Sciences, Bangalore study:

Yoga group had significantly (p = 0.001, Mann Whitney) better improvement in LVEF than control group in those with abnormal baseline EF (<53%) after 1 year. There was a better reduction in BMI in the yoga group (p = 0.038, between groups) in those with high baseline BMI (≥ 23) after 12 months. Yoga group showed significant (p = 0.008, Wilcoxon’s) reduction in blood glucose at one year in those with high baseline FBS ≥ 110 mg/dl. There was significantly better improvement in yoga than the control group in HDL (p = 0.003), LDL (p = 0.01) and VLDL (p = 0.03) in those with abnormal baseline values. There was significantly better improvement (p = 0.02, between groups) in positive affect in yoga group.

Within Yoga group, there was significant decrease in perceived stress (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), and negative affect (p = 0.03) while in the control group there was reduction (p = 0.003) only in scores on anxiety. Addition of yoga-based relaxation to conventional post-CABG cardiac rehabilitation helps in better management of risk factors in those with abnormal baseline values and may help in preventing recurrence.

General Yoga Guidelines and rules for post-operative surgery:

• Ahimsa is an integral part of yogic principle which includes harm to self. So, if it hurts, don’t do it. Practice a non-judgemental attitude while doing yoga.

• Traditional yoga classes which are slow, gentle, having relaxation poses are preferred than types like hot yoga, anti-gravity and Bikram yoga.

• Don’t over exert yourself, but don’t be a slug. Hatha yoga talks about balancing every action in life achieving a state of harmony and equilibrium. Staying within certain range of motion parameters and always avoiding any position that causes pain is vital.

• Eating nutritious foods helps your body heal and improves your immune system as your body recovers. Yogic diet focuses on both qualitative and quantitative rules for eating which should be followed. No more than half the capacity of stomach should be filled with solid food even after patient is shifted on full diet. Including ghee (clarified butter) also helps in improving digestive fire and aids digestion.

• Pathyakar and sattvic food which is light, hot, easy to digest, freshly cooked and nutritious in nature should be consumed post-surgery.

• Everyone’s recovery is different, and every form of activity has its own risks. Personalized advice from yoga instructors or medical professionals is a great way to ensure safety. Always consult your surgeon if you have concerns about your recovery.
• No deep twisting, large backbends, or focused core work for at least 4 weeks after abdominal surgery.

• For laparoscopic or robotic surgery patients, yoga practices are advised after consulting the surgeon and yoga teacher together. For joint replacement surgeries, bahiranga practices like asanas can be resumed only after three months but antranga practices like meditation, chanting and yoga nidra can be experienced.

• In ACL surgeries it has been found that the more oxygenated blood that reaches the ACL ligament, the quicker the recovery process will be. Hence yogic breathing techniques, pranayama and slow sukshma vyayama should be practised under certified yoga therapist.

• Patients must be aware of any specific precautions to take based on their medical history, type of surgery, the surgical technique used, and type of implant.

The integrated yoga intervention post-surgery should include simple and safe practices at physical, mental, emotional, intellectual levels to reach a state of mastery over the modifications of the mind (Chitta Vritti Nirodhah- definition of yoga by sage Patanjali) through effortless blissful inner awareness during all practices. Yoga after surgery been helpful in flexibility, muscle strengthening, relaxation, stress and pain relief, and even improvement in digestion. Yoga can help improve posture with stretches and by increasing awareness of body alignment and one’s new joint. Finally, we can say that Yoga can help with stress relief, insomnia, postoperative pain and overall recovery process in surgical recovery of patients.