Assessment of the Severity of Disease in Patients with Bronchial Asthma, Before and After Yoga: A Randomised Trial

Introduction: Asthma is a common chronic infl ammatory disorder affecting about 300 million people worldwide. As a holistic therapy, yoga has the potential to relieve both the physical and psychological suffering of people with asthma, and its popularity has expanded globally. Yoga includes several techniques: physical postures (asanas), voluntarily regulated breathing (pranayama) and meditation. Materials and Methods: Sixty patients with bronchial asthma underwent training for eight weeks in an integrated set of yoga exercises, including breathing exercises, suryanamaskar, yogasana (physical postures), pranayama (breath slowing techniques), dhyana (meditation) and were told to practice these exercises for 65 minutes daily. They were then compared with a control group of sixty patients with asthma matched for age, sex, and type and severity of asthma, who continued to take their usual drugs. Their daily records were used to assess the number and severity of attacks and the medication used by them. Apart from that, Group A patients also kept a record of the Yogic Exercises performed by them twice daily. Results: There was a signifi cantly greater improvement in the group who practiced yoga in the weekly number of attacks of asthma, scores for drug treatment, and peak expiratory fl ow rate. Conclusion: This study showed the effi cacy of yoga in the long term management of bronchial asthma, but the physiological basis for this benefi cial effect needs to be examined in more detail. Research Article Assessment of the Severity of Disease in Patients with Bronchial Asthma, Before and After Yoga: A Randomised Trial Candy Sodhi1, Amit Bery2* and Sheena Singh3 1Associate Professor, Physiology Department, CMCH Ludhiana 2Associate Professor, Medicine Department, DMC and Hosp, Ludhiana 3Professor and Head, Physiology Department, CMCH, Ludhiana Received: 30 April, 2018 Accepted: 10 May, 2018 Published: 11 May, 2018 *Corresponding author: Amit Bery, Associate Professor, Medicine Department, DMC and Hospital, Ludhiana, India. E-mail:


Introduction
Asthma is a chronic infl ammatory disorder of the airways in which many cells and cellular elements play a role. The chronic infl ammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or in the early morning. These episodes are usually associated with widespread but variable airfl ow obstruction that is often reversible either spontaneously or with treatment [1].

The use of complementary and alternative medicines (CAM)
for asthma treatment is of great interest in patient care [2,3].
Yoga therapy readjusts the autonomic imbalance and controls the rate of breathing and thus alters various physiological variables. These changes are attributed to the decreased sympathetic reactivity and relaxation of voluntary inspiratory and expiratory muscles [8,9].
The practice of breathing exercise increases parasympathetic activity and decreases sympathetic activity, improves cardiorespiratory functions by affecting oxygen consumption, metabolism and skin resistance [10].
Thus yogic practices like pranayama may be useful in patients of perennial bronchial asthma with mild to moderate symptoms.

Aim
To assess the effect of yoga on severity of the disease and peak expiratory fl ow rate (PEFR) in patients with bronchial asthma.

Materials and Methods
The present study on one hundred and twenty nonsmoking patients of either sex, in the age group of 17-50 years, diagnosed with mild to moderate grades of bronchial asthma and recruited from Christian Medical College & Hospital, Ludhiana and from the yoga camps organized by renowned yoga experts, in Ludhiana was conducted in the Departments of Medicine and Physiology of this institution between October 2005 and March 2007. The recruited patients were randomized in two groups i.e. Group A and Group B.

Group A:
Yoga training group

Control group
Diary record: (refer Appendix 1) Detailed information was provided for maintaining diaries. They were all also provided with a sample of the diary page. Patients maintained regular diary records at home and recorded the number and severity of attacks and the medication used by them. Apart from that, Group A patients also kept a record of the Yogic Exercises performed by them twice daily.
At each visit information from patient diary were recorded. Their diary records were counter checked by asking relevant questions during their visits.

Entry in diary
A. At start of the study period -A history of various events in last 2 months for both the groups were recorded.   Remained same.

Increased.
Peak expiratory fl ow rate (PEFR): This was estimated on the patients of both the groups at baseline, after 4 weeks and then after 8 weeks. The pulmonary function tests were done on a computerized spirometer, MEDSPIROR.
Mild attacks -Did not disturbs sleep or daily routine.
Moderate attacks -Disturbs sleep and daily routine and relieved by oral drugs.
Severe attacks -Requires intravenous drugs or admission to hospital.
Instructions -Please Enter the Record and Tick the appropriate boxes.

Statistical analysis
The comparison of the pre and the post value across the study and the control group was done using repeated measures Analysis of Variance (R M ANOVA).
Comparison of proportion showing clinically signifi cant improvement after making adjustment of compounding factors like age, duration of disease etc were carried out by using logistic regression analysis.

Results
As per the patients' "diary records" the "number of attacks per week scores", showed a decline in Group A, which was signifi cant at 8 weeks as compared to the baseline (p < 0.01) and 4 weeks (p < 0.05), while the scores in Group B showed an increase over time. The difference in scores at 8 weeks between Group A and Group B was statistically signifi cant (p < 0.05) ( Table 1).
As per the patients' "diary records" the "severity of attacks score" showed a steady and signifi cant decline in Group A from baseline to 4 weeks to 8 weeks, while scores in Group B showed an increase over time. The difference in scores at 8 weeks between Group A and Group B was statistically signifi cant (p < 0.05) ( Table 2). As per the patients' "diary records" the "dosage of drugs required score" during the study period were higher in Group B than in Group A, at all times, but the differences were statistically not signifi cant (p > 0.10 at all times). Group A scores showed a decline over time, which was statistically signifi cant when compared between baseline and 8 weeks (p < 0.05), while Group B scores showed an increase over time ( Table 3).
Percentage of predicted PEFR was higher in Group A subjects than in Group B at all periods of measurement, but the differences were statistically not signifi cant (  (Table 4).

Discussion
In the present study, diary records regarding the daily number of attacks, severity of attacks and the dosage of medication required were maintained by all the patients in the two groups.
The scores for "number of attacks per week" at baseline were comparable between the two groups (p > 0.10). While the scores at 4 weeks also remained comparable between the two groups, the difference between this diary record score In the same study, the reduction in the severity of asthma attacks scores however showed no signifi cant difference between the yoga and control groups.   Symptom scores in the study by Murthy et al. [7], showed signifi cant reduction after 15 days breathing training in males and after 45 days training in females.
In the study by Singh et al. [14], compared with the baseline, inhaler use decreased more with PCL exerciser than with the placebo device, but the changes were small and the difference between the two devices were not signifi cant.
Murthy et al. [7] reported that the mean drug scores of patients requiring oral bronchodilators reduced signifi cantly from their initial values of 2.71 ± 1.54 after breathing training, but patients on steroids as well as bronchodilators did not show any signifi cant reduction in their dosage schedule.
The study by Nagarathna and Nagendra [4] also showed signifi cant benefi cial effect of pranayama on drug usage (p < 0.01) after a 54 months' yoga training program.
In the study by Cooper et al. [15], however, bronchodilator use was reduced in patients who practiced Buteyko breathing technique, but there was no change in those who practiced pranayama.
Thus in our study the "diary record scores" for number of attacks per week, severity of asthma attacks as well as requirement of drugs showed signifi cant improvement after pranayama training of 8 weeks. However, drug usage showed no difference between the pranayama training group and control group at 8 weeks. This, however, may have been different if the training period could have been increased, as evidenced in the study by Nagarathna and Nagendra [4] where 54 weeks of training showed signifi cant reduction in drug usage.

Conclusion
In the present study on one hundred and twenty nonsmoking patients diagnosed with mild to moderate grades of bronchial asthma, pranayamic breathing training, used adjunctively with standard treatment, proved to be benefi cial in terms of patients' own assessment of number of asthma attacks per week, the severity of the attacks and the dosages of medication required by them. This was further reinforced by the signifi cant increase in the PEFR as measured by medspiror in patients who were preformed yoga.
Given the current tendency of patients and medical practitioners to explore and to lean towards alternative therapeutic modalities, particularly those which involve a natural approach rather than the pharmacological interference by allopathic treatment, we, on the basis of the fi ndings of this study, would want to recommend yogic training, especially pranayama, to sufferers of such chronic diseases as asthma.
However, it needs to be pointed out that this study involved only sixty patients in either group who were studied for a period of eight weeks only. Also, the study included nonsmokers with mild to moderate asthma only.
Further studies with larger sample sizes and longer follow up should be undertaken and the effect of pranayama in asthmatics who smoke and in severe grades of asthmatics should be evaluated.