Yoga For Bronchial Asthma: A Controlled Ctudy

Yoga For Bronchial Asthma: A Controlled Ctudy R. Nagarathna, H.R. Nagendra Vivekananda Kendra Yoga Research Foundation, Bangalore, India.

Abstract : Fifty three patients with asthma underwent training for two weeks in an integrated set of yoga exercises, including breathing exercises, suryanamaskar, yogasanas (physical postures), Pranayama (breath slowing techniques), dhyana (meditation), and a devotional session, and were told to practice these exercises for 65 minutes daily. They were then compared with a control group of 53 patients with asthma matched for age, sex, type and severity of asthma who continued to take their usual drugs. There was a significantly greater improvement in the group who practiced yoga in the weekly number of attacks of asthma, scores for drug treatment, and peak flow rate. This study shows the efficacy of yoga in the long term management of bronchial asthma, but the physiological basis for this beneficial effect needs to be examined in more detail. INTRODUCTION Yoga has been used to treat patients with asthma for over 50 years in yoga centers in India. Goyeche et al and several other workers have shown convincing evidence of the beneficial effects of yoga in patients with bronchial asthma. Most of these studies were short term, performed without controls, or qualitative but based on subjective judgments. Our earlier investigation clearly indicated the short term (two to four weeks) benefits of yoga, as established by standard controlled studies on large numbers of patients who underwent yogic training as outpatients. Prospective long term studies using standardized research procedures are however unavailable. It is well known that the clinical course of a disease like chronic bronchial asthma is highly variable, being subject to many known and unknown factors. We carried out this long term study with matched controls to ascertain whether yoga could have lasting influence on the course of the disease. PATIENTS AND METHODS Table 1 shows details of 106 patients with established bronchial asthma satisfying the clinical criteria of Crofton and Douglas and Shivpuri that were included in this study. The age range was 9 - 47 years with a mean of 26.4 years. There were 15 women in each group. Fifty three pairs of patients matched for age, sex and type, severity, and duration of asthma were selected from a bigger group who came to our out patient clinic for yoga therapy. One from each pair was randomly selected for training in yoga, and the other served as control. Although all 106 patients were equally motivated to take up yoga, the 53 randomly allocated patients willingly served as controls. They continued taking their usual drugs during the study. All techniques of measurement, the length of each interview, and the people recording the data were the same for both groups. The yoga group attended a training programme of two and a half hours daily from 18.00 to 20.30 hours after work for two weeks. They were introduced to an integrated programme of the following selected yoga exercises. Table 1 Details of Patients Breathing exercises (5 minutes)- five types of rhythmic, comfortable breathing techniques associated with simple hand and body movements, Sithilikarana vyayama (Yoga exercises to loosen the joints) and suryanamaskar (five minutes). Yogasanas- (a) General yogasanas (20 minutes). Simple physical postures (in the standing, sitting, prone, and supine positions), performed with smooth, comfortable bending movements and slow breathing procedures. The asana practices end with the subject maintaining the final posture with the body relaxed (b) Savasana (10 minutes). Deep relaxation to relax the muscles regionally followed by conscious slowing of breathing and calming of mind. Pranayama (10 minutes)- Four types of special breathing techniques performed with comfortable, slow, deep breathing. Meditation and devotional session (15 minutes)- slow mental chanting of the syllable "OM" leading to slowing of mental activity. The devotional session was meant to harness the emotions, resulting in a feeling of freedom. Kriyas (weekly)- Traditional voluntary nose and stomach wash techniques (neti and vamana dhouti) followed by Savasana. Lectures and discussions - These were based on yoga philosophy and therapy. We instructed 53 patients to continue the 65 minutes of yoga daily during the follow up period. For the purpose of analysis those patients who stopped the practices or did not practise for more than 16 days each month were eliminated from the study. Although we continued to record their progress. Twenty five patients dropped out of the study: seven after six months of follow up, seven after 12 months, two after 18 months, four after 24 months, and five after 30 months. All patients reported for check ups at intervals of six months. The frequency of visits and the relationship between doctor and patients were the same for both groups. At the initial interview patients were instructed to keep a diary. They were told to record each attack of airway obstruction, it's severity, and the dosage of the drugs they consumed. They continued to take prescribed bronchodilator drugs throughout the study. When they noticed an improvement or deteriotatation in their asthma they were permitted to change their dosage as required, and they recorded this in their diaries. Any change in the brand of drug, however, was decided by the doctor. At each of the follow up visits information from patients diaries and from clinical examinations was recorded. The mean weekly number of attacks for each period of follow-up was calculated severity of attacks was graded: 1=mild, but did not disturb sleep or daily routine; 2=moderate, disturbed sleep and daily routine and was relieved by oral drugs; 3=severe, required injection or admission to hospital. We obtained a score for drug treatment by calculating the mean number of bronchodilator tablets and injections taken each week for each period of follow up. None of the patients used inhalers. Peak expiratory flow rate was obtained by recording the best of three attempts on a mini Wright Peak flow meter. DISCUSSION As care was taken to match the two groups for age and sex and type, severity, and duration of asthma, we can attribute the improvement seen in the variables measured in the 53 patients in the Yoga group to the regular practice of yoga. The considerable reduction in their drug treatment score in contrast with a non-significant increase in intake of drugs in the control group strengthens this view, as do the significant differences between the groups in the number of attacks per week and peak flow rate. McFadden clearly showed that the responsiveness of airways is noticeably increased in patients with asthma, who develop bronchoconstriction in response to smaller quantities of physical, chemical, and pharmacological stimuli than healthy subjects. A complex interplay of several factors namely, an inherent responsiveness of the smooth muscle to stimuli, an abnormality in autonomic nervous control, and a breakdown in airway defences may promote bronchial hyper-reactivity. Thus reducing the responsiveness of the tracheobronchial tree could benefit these patients considerably. Abundant objective data now exist indicating that psychological factors can interact with the asthmatic diathesis to worsen or improve the course of the disease. The mechanisms of these interactions are complex and not well understood, but psychological factors may affect about half of all patients. Modification of vagal efferent activity seems to affect the calibre of airways. It has been shown that suggestion can actually decrease or increase the effects of pharmacological stimuli on the airway. The role of the psychic factor in inducing or prolonging attacks in acute exacerbations may vary from patient to patient and in individual patients from episode to episode. Goyeche et al claimed that the psychosomatic imbalance is present in many, if not all patients with asthma1. Suppressed emotion, anxiety, dependence, and extreme self consciousness may all be accompanied by generalised and localised muscle tension, including that of the voluntary respiratory musculature. This increased muscle tension may be a precipitating or concomitant factor that perpetuates and aggravates the asthmatic syndrome. Yoga seems to stabilise and reduce the excitability of the nervous system. Transcendental meditation (a traditional yogic meditation technique) and Savasana have been clearly shown to be associated with reduced metabolic rate2. Crisan showed a significant reduction in the level of anxiety after the practice of Pranayama, as evidenced by increased skin resistance and a reduction in pulse rate, urinary catecholamine concentration, Urinary cholinesterase activity, and anxiety scores12. Several workers have found an increase in alpha synchrony in electroencephalograms taken during transcendental meditation, which points to its stabilising effect on the nervous system. Yoga clearly relaxes the muscles and this deep physical and mental relaxation associated with the physiological changes seen in our patients after daily yoga seems to have a stabilising effect on bronchial reactivity, thus making the vagal efferent less excitable. In conclusion, the reduction in psychological hyper-reactivity and emotional instability achieved by yoga can reduce efferent vagal reactivity, which has been recognised as the mediator of the psychosomatic factor in asthma. REFERENCES 1. Goyeche J R M, Abo Y, Ikemi Y: The yoga perspective part II. Yoga therapy in the treatment of asthma. J of Asthma 1982-19; 189 - 201. 2. Bhole M V: Treatment of bronchial asthma by yogic methods - a report. Yoga Mimamsa 1967,9 37-41. 3. Bhole M V: Rationale of treatment and rehabilitation of asthmatics by Yoga methods - Collected papers on yoga, Lonavla, India Kaivalyadhama 1975; 106-114. 4. Erskin J, Schonnel M: Relaxation therapy in bronchial asthma J. Psychosom Res. 1979;23;131-139. 5. Honsberger R, Wilson A F: Transcendental meditation in treating asthma. Respiratory Therapy 1973;3;79-81. 6. Murthy K J R, Sahay B K, Sitaramaraju P. et al: Effects of pranayama (rechaka, puraka and kumbhaka) on bronchial asthma - an open study. Lung India 1993;5;187-191. 7. Nagarathna R, Nagendra H R: Studies on bronchial asthma 1981-88. Bangalore, India: Vivekananda Kendra Yoga Research Foundation (Report 1-4, 8-11). 8. Crofton J, Douglas A: Respiratory diseases, 2nd Ed. Oxford Backwell Scientific Publication, 1975; 429. 9. Shivpuri D N.: Studies on methods of clinical research in bronchial asthma and allied conditions. Aspects of allergy and applied immunology 1974;7,15-35. 10. Mc Fadden E R, Pathogenesis of asthma. J Allergy & Clinical Immunology 1984; 73, 411-422. 11. Patel C H: Twelve month follow up of yoga and biofeedback in the management of hypertension, Lancet 1975.1,62-3. 12. Crisan H G: Pranayama in Anxiety neurosis - a pilot study. Heidelberg, University of Heidelberg 1984 (Ph.D. dissertation) (Accepted in Aug 1985).