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Indian J Allergy Asthma Immunol 2006; 20(2) : 98-104

Role of Pranayama in Rehabilitation of COPD patients - a Randomized Controlled Study

S K Katiyar, Shailesh Bihari Dept. of Tuberculosis and Respiratory Diseases Dr. Murari Lai Chest Hospital G.S.V.M. Medical College, Kanpur
Abstract Effects of Pranayama was studied on COPD patients considering PFT, blood gases, 6MWT and SGRQ scores and compared with control. Forty eight patients with severe COPD were randomly divided (24 each) into two groups. Group 1 patients were trained to do paranayama for 3 months for at least half an hour duration. Both the groups were allowed to continue with their usual physical activity and medications. Spirometry, ABG, 6MWT was done and SGRQ scores were measured before and after study. Training-induced changes were greater in group 1 than 2 for following variables: increase of FVC (% predicted) from 68 4.2 to 72 3.9 (p=0.11), FEV1 (% predicted) from 48 2.4 to 52 2.1, (p=0.15), PEF (%predicted) from 24.2 0.9 to 30.1 0.8 (p<0.05), 6MWT from 262 38 to 312 47 m (p<0.05). There was decrease in scores of symptoms (72 2.5 to 66 2.9, p<0.03), activity (66 2.1 to 50 1.7, p<0.005), impact (53 2.9 to 39 1.8, p<0.008) and total score (55 2.9 to 48 2.3 p<0.02) in group 1 but not in group 2 patients. Key words: Pranayama, COPD - Chronic obstructive pulmonary disease. SGRQ - St. George's Respiratory Questionnaire. -6 MWT- Six minute walk test

INTRODUCTION Comprehensive pulmonary rehabilitation programs

dependent on family, friends, health professionals a expensive medical resources.

At present, medical treatment of COPD

are well establish to enhance standard medical therapy predominantly tocused on the primary ore and reduce disability in patients with chronic lung dysfunction. Despite optimal medication, there is diseases I he primary goal is to restore the patient to the highest possible level of independe n t f u n c t i o n . 1 his can be accomplished by helping patients to become knowledgeable about their disease, actively involved in their own health care, independent in which the latter is clearly related to the diminish' performing daily care activities and therefore less muscle function/ Diminished muscle function is part the result of the commonly occurring muse . . . wasting in patients with COPD, its prevalen. increasing from 20% in clinically stable outpatient up to 35% in patients eligible for pulmona: 98 weak relationship between the primary org impairment and disability/experienced handicap. T most important complaints of patients with COPD a d y s p n e a1 a n d a n i m p a i r e d e x e r c i s e p e r f o r m a n c e ,

Address for correspondence: Dr. Shailesh Bihari. 113/1 Alopi Bagh Allahabad 211006, Uttar Pradesh Ph: +91-9940217726 Email id:, UAAI. 2006, XX (2) p 98-104.



rehabilitations.4 To improve muscle function and exercise capacity in patients with COPD, pulmonary rehabilitation is currently accepted as evidence-based intervention strategy. 5 The health benefits of adequate physical activity are well-recognized. 6 Recommendations for physical activity have evolved to the current ones of physical activity of at least a moderate intensity for 30 minutes on all or most days of the week.7 Despite the benefits of physical activity and the existence of national recommendations, the majority of the patients remain insuffic iently active.8 The word yoga means 'union': union of mind, body and spirit - the union between us and the intelligent cosmic spirit of creation- 'the oneness of all things'. Recent scientific studies9 "17 have shown the beneficial role of yogic exercises in management of asthma. Role of yogic exercises in management of cardiac diseases 18 , diabetes19 , chronic pancreatisis20 , depressive disorders21 , epilepsy22 , osteoarthritis 23 , multiple sclerosis 24 , even for tuberculosis 25 and pleural effusion26 have been reported, The five principles of yoga are relaxation, exercise (asanas), pranayama (breathing control), nourishing diet, and positive thinking and meditation, Pranayama are yogic breathing techniques that increase the capacity of lungs.27 "29 help to strengthen the internal organs, improve mental control21 and deepen your ability to relax30. According to yogic belief, life expectancy is linked to the frequency of respiration if we can learn to slow down our breathing, we can add years to our lives. Yogic breathing or pranayama is part of all yogas and is one of the practices of kundalini yoga. It is the art of controlling the breathing. When patients with COPD were nonspecifically trained31 the strength of both the inspiratory and expiratory muscles was increased, with beneficial effects on exercise performance and quality of life. In the present study, we have recorded the effects of Pranayama in patients with severe COPD based on the pulmonary function parameters, blood gases, symptoms, activity and impacts scores of the patients. MATERIAL AND METHODS Forty eight patients (40 men and 8 women) with Spirometric evidence of severe chronic air-flow

limitation (ie., FEV1 of < 50% of predicted and FEV1/ FVC ratio of < 70% of predicted) were recruited for the study using the St George's Respiratory Questionnaire. They were all observed during a 4week run- in period, in which their regular treatment was maintained, to verify stability in their clinical and functional status. Patients with age < 40 years, unwilling to give consent, cardiac disease, poor compliance, a requirement for supplemental oxygen therapy, recent hospitalization or CO2 retention (Paco2 > 50 mm Hg), history or spirometric evidence of asthma, evidence of cor pulmonale, abnormal liver, renal or hematological profile were excluded from the study. STUDY DESIGN This was prospective randomized control study. Patients were randomized using computer generated randomization into two groups: 24 patients were trained to do pranayama for 3 months for at least half an hour duration daily in addition to their usual physical activity and medications, and 24 patients were assigned to be in a control group who were allowed to continue with their usual physical activity and medications for the same duration. All the data were collected by the same collector who was blinded to the different group. The study protocol was approved by the institutional ethics committee, and informed consent was obtained from all the subjects. The following tests were performed before and within 1 week after the completion of the study. Spirometry: FVC, FEVj and PEF were measured three times on a computerized spirometer (spirobank G), and the best reading was reported. 6-Minute Walk Test: The distance the patient was able to walk in 6 min was determined in a measured corridor as described by McGavin and coworkers32-33 . The patients were instructed to walk at their fastest pace and cover the longest possible distance in 6 minutes under the supervision of a doctor. The test was performed twice, and the best reading was reported. Arterial Blood Gas Analysis: Both po2 and pco2 levels were measured and reported

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St George's Respiratory Questionnaire (SGRQ): It is designed as a supervised self-administered questionnaire34 -35 . The patients completed the questionnaire themselves under supervision of a para medical staff. Three component scores were calculated for the SGRQ. Symptoms - This component is concerned with the effect of respiratory symptoms, their frequency and severity. Activity - Concerned with activities that cause or are limited by breathlessness. Impacts - Covers a range of aspects concerned with social functioning and psychological disturbances resulting from airway disease. A Total score: It summarizes the impact of the disease on overall health status - over the last three months. Scores are expressed as a percentage of overall impairment where 100 represents worst possible health status and '0' indicates best possible health * status. , > Training Protocol: In all patients of the study group, several practice sessions were done before starting the study in order to optimize the possible training effect. Subjects in this group were asked to do pranayama daily, six times a week, each session consisting of at least 1/2 h. Pranayama consisted of six Asanas (exercises) Bhastika Pranayama 'Kapalabhati Pranayama Vhasya pranayama, Anulom-Vilom pranayama, Bhramid pranayama and Udgeedh pranayama. Patients in the control group were allowed to continue with their usual physical activity. Yoga was performed under the supervision of yoga Instructor. Data analysis: SPSS software (version 11 Chicago) was used for all the statistical analysis and results are expressed as mean standard deviation. Comparisons of lung function, the 6-min walk test, ABG and the SGRQ in the two groups were carried out using the Student Newman- Keuls tests. All the tests were 2 tailed and critical value of p was set at 0.05.

Table 1. Clinical characteristics of Patients with COPD at basi Characteristics Age, yr Male/female sex, No. Weight, kg Height, m FVC,L % predicted FEV,,L % predicted PEF(L/sec) % predicted PaO2, mm llg PaCO2. mmHg 6-min walk distance, m SGRQ score (Symptoms) SGRO score (Activity) SGRQ score (impacts) Study Group (n = 23) 53.3 2.9 18/5 52.6 2.4 1.62 3.7 2.12 0.8 68 4.2 1.07 0.4 48 2.4 1.760.4 24.2 0.9 74 4.1 42 1.1 242 38 72 2.5 66 2.1 53 2.9 Control G (n = 2 51.1 : 20/2 50.7 : 1.61 I 2.20 ( 69 3 1.02 48 2 1.68C 23.5 ( 75 4. 41 1. 266 4 75 2. 63 2. 51 1.

SGRQ (Total score) 55 2.9 54 2. ^

RESULTS One patient from the study group and two patie from the control group withdrew from the study a the results were compiled from the remaining patients. There were no differences between the V groups in age, height, weight and spirometric valu ABG and SGRQ scores at the entrance to the stuc (Table 1) Spirometry There was a small but insignificant increase FVC of predicted) and FEV1 (% of predicted) in t study group (from 68 4.2 to 72 3.9, p = 0.16 a from 48 2.4 to 52 2.1, p = 0.28) but not in t control group. PEF (I/sec) also demonstrated a small b significant increase (% of predicted) in study groi (from 24.2 0.9 to 30.1 0.8, p = 0.05) but not in t control group Fig 1(3).

Fig 1. (ABCD) Spiromateric value and 6MW test bef >re and after intervention in study and control group

Blood Gas Analysis Following the study period, there were no significant changes in the blood gas values either in study or in control group. 6-Minute Walk -Test There was a small but significant increase of 19% (from 242 38 to 292 47 m, p = 0.05) in the distance walked in 6 min, in the study group but not in the control group Fig 1(4).

St. George's Respiratory Questionnaire (SGRQ) SGRQ: There was statistically significant decrease in the symptoms score (from 72 2.5 to 66 2.9, p = 0.03), activity score (from 66 2.1 to 50 1.7, p < 0.005), impact score (from 53 2.9 to 39 1.8, p < 0.008) and the total score (from 55 2.9 to 48 +2.3 p = 0.02) in study group but not in control group. The threshold for a clinically significant difference between groups of patients and for changes within groups of patients is four units35 (Fig 2).


v ____________

' I

D Total Score (Before) Total Score (After) Fig D : SGRQ-Total score

Fig C : SGRQ-Impact score

Fig 2. (ABCD) SGRQ score before and after intervention in study and control group covering all the 4 domain of SGRQ


The present study has demonstrated that in patients with sign.ficant COPD if specially trained for Yogic breathing called pranayama, show deceastruted improvement of lung functjon parameters, improvement in the exercise tolerance, symptoms score, their usual activity and reduction on the impact of disease on their lives. Pulmonary rehabilitation per se results in exercises (pranayama) on airway reactivity in improvements in health status.36 -37 Several studies subjects with asthma and reported a statistical have shown that specific inspiratory muscle training significant increase in the dose of histamine neede

may diminish the sensation of respiratory effort,3 * increase the capacity to walk, and improve the quality of ,. fe fa patients wjth COPD 39,40. It has also been shown 3i that trajning both inspiratory and eXpiratory musc ,es resu ,ts in improved exercise performance , health-related quality of life, and decreased dyspnea in daily activities



to provoke a 20% reduction in FEV1 in patients using pranayama breathing. A parallel group, double blind, randomized controlled trial from Australia 16 has shown that the practice of Sahaja yoga does have limited beneficial effects on some objective and subjective measures of the impact of asthma, others17 have reported a decrease in the use of beta agonist with the practice of yogic exercises in asthmatic subjects. Other studies41 -42 have shown no benefit of yoga in asthma patients. Two studies by Nagendra and Nagarathna14'15 showed the beneficial effects of yoga breathing exercises for asthmatic patents. In the first study, peak expiratory flow rate values improved after yoga, and a majority of the patients were able to stop or reduce their cortisone medications. The second study showed overall decrease in asthma attacks and medication usage in patients using yoga breathing. A study on effect of yoga on COPD43 patients showed that lung function parameters (FVC, FEV1, and PEFR) improved after the practice of yoga and indicated that, yoga may be a useful adjunct to other conventional form of therapy for COPD. Some studies27 "29 '43 have shown beneficial effect of yogic exercises on lung function parameters. In our study, there were significant improvement only in PEFR and improvements in FVC and FEV1 values were insignificant after 3 months of yogic training. There has been a case report44 of occurrence of pneumothorax with practice of Kapalabhati pranayama but there was no such occurence in our study. We conclude that pranayama (Yogic breathing) has an overall positive effect on patients with moderate-to-severe COPD. There was improvement in the lung function parameters. Patients had reduced symptoms, became more actively involved in their own health care, more independent in performing their daily activities increased exercise tolerance and therefore less dependent on family, friends, health professionals, and expensive medical resources. There was improvement in the psychological function of the patient with less anxiety and depression and increased feeling of hope, control and self- esteem . Yogic breathing is a noncompetitive, personal, inexpensive and enjoyable activity which can produce truly amazing results.

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