Original Article

Effect of Adjuvant Yoga Therapy on Pulmonary Function and

Quality of Life Among Patients with Chronic Obstructive
Pulmonary Disease : A Randomized Control Trial

Soccalingam Artchoudane1, Pajanivel Ranganadin2, Ananda Balayogi

Bhavanani3,*, Meena Ramanathan3, Trakroo Madanmohan1
1
Centre for Yogic Sciences,
Aarupadai Veedu Medical ABSTRACT
College & Hospital, Background and Objectives: Previous studies have suggested that yoga positively
Vinayaka Mission’s Research impacts lung function and quality of life (QoL). The present prospective two-arm,
Foundation, Kirumampakkam, single-blinded and controlled study evaluated the effect of adjuvant yoga therapy on
Puducherry-607402, pulmonary function and QoL in patients of Chronic Obstructive Pulmonary Disease
2
Department of Pulmonary
(COPD).
Medicine , MGMCR&I, Material and Methods: Seventy two COPD patients were recruited and randomized
to yoga group who received adjuvant yoga therapy in addition to standard medical
3
Centre for Yoga Therapy,
management and control group who received only medical management. Yoga
Education and Research therapy protocol included loosening exercises, postures, breathing techniques and
(CYTER), relaxation. Forced vital capacity (FVC), forced expiratory volume in first second
Sri Balaji Vidyapeeth, (FEV1) and FEV1/FVC were measured using computerized pulmonary function
(Deemed to be University), test ‘Trueflow (ndd)’. Saint George Respiratory Questionnaire (SGRQ) was used
Pillaiyarkuppam,
to asses QoL. Changes in parameters were correlated with symptoms, activity,
impacts and quality scores. Intra-group comparisons were done using Student’s
Puducherry-607402.
paired ‘t’ test and intergroup comparisons using unpaired ‘t’ test.
Results: There was significant improvement (p < 0.001) in FVC and FEV1 after four
weeks of adjuvant yoga therapy while controls showed decline in all parameters.
QoL scores, namely: symptoms , activity , impacts and quality improved significantly
in yoga group with no significant changes in controls. Significant correlation was
found between pulmonary function and QoL in Yoga group.
Conclusion: Significant improvements of lung function with adjuvant yoga
therapy can be attributed to comprehensive yoga therapy package administered to
participants resulting in decreased airway resistance and better lung compliance
attributed to nonspecific broncho-protective / broncho-relaxing effect. Significant
improvement in QoL scores can be attributed to improved vital capacity as well as
enhanced self-confidence /self-reliance. We conclude that there is a positive and
. additive role of adjuvant therapy with standard medical management of COPD.
For Correspondence
Keywords:
*Dr.Ananda Balayogi Bhavanani
Lung function, Saint George Respiratory Questionnaire, yoga therapy
Email: [email protected]
Date of
Submisssion: 15-06-2018
Acceptance: 05-08-2018
INTRODUCTION worldwide, whereas its social burden
Chronic Obstructive Pulmonary will rank fifth.2 The Global Initiative
Disease (COPD) is an important cause for Chronic Obstructive Lung Disease
of morbidity and mortality and it is (GOLD) management includes a
Access this article online a major public health problem.1 The reduction in symptoms, complications,
Quick Response Code condition is characterized by irreversible
and exacerbations, improved exercise
airflow obstruction, a gradual decline
tolerance, improved health status
in lung function, loss of lung tissue,
and reduced mortality.3 Dyspnea, the
reduced quality of life, and high rate
hallmark symptom of COPD is the
of mortality. reason for which most patients seek
medical attention and is a major cause
By 2020, COPD is predicted to of disability and anxiety associated with
https://www.jbcahs.org
rank as third leading cause of death the disease.4

SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018 117
 Soccalingam Artchoudane et al: Effectiveness of adjuvant yoga therapy in COPD

Prana, the life force, promotes mind-body was also registered on the Clinical Trial Registry-India
harmony. Yoga practices, especially pranayama help (CTRI: ctri/2017/11/010597).
in restoring the harmony thereby promoting health
and well being.5 Prana vitalizes organs responsible for Inclusion and exclusion criteria: COPD patients
respiration. Asthma, COPD and airway restrictions with lung function less than 70% of predicted values
are the most troublesome chronic diseases for lifetime. and who were willing to participate and able to
Drug therapy alone does not work because it does not perform techniques given in the protocol (Table 1) were
deal with the problem.6 Yoga helps to maintain the recruited for the study after obtaining their informed
state of equilibrium whereby the health and strength consent. Those with active infection of lungs especially
of body and mind are acquired by enhanced prana. pulmonary tuberculosis and evidence of complications
were excluded.
Yoga therapy has a positive impact on lung function
and exercise capacity and can be used as an adjunct Table 1: Components of yoga therapy protocol for COPD
pulmonary rehabilitation program for COPD patients
which are a known cause to increase the level of stress, S. No. Name of practice Duration
emotional vulnerability and physical inactivity. A 1 Prayer 3 min
comprehensive yoga program can have a salutary effect 2 Loosening exercises 7 min
on general health and respiratory health increasing a
person’s ability to perform activities. 3 Matsyasana 3 min
4 Shashahasana 3 min
Vedanthan observed that one of the most important 5 Mahamudra 3 min
aspects of yoga for asthma and COPD patients is 6 Chiri kriya 3 min
that they develop an increased capacity to relax and
control their breathing, which is more effective with 7 Sharabhasana 3 min
regular practice.7 Brain’s cortico-limbic-hypothalamic 8 Vibhaga pranayama 5 min
systems get modulated by pranayama, asana and 9 Bhastrika pranayama 5 min
meditation, which enhances the autonomic, endocrine 10 Bhramari pranayama 5 min
and somatic responses correlated with homeostatic
11 Kaya kriya 3 min
response to negate the undesirable effects of stress.7
Yoga therapy improves Quality of life (QoL) and lung 12 Spanda nishpanda 2 min
function even on a short-term basis.8 Donesky and 13 Makarasana 3 min
colleagues also reported an improvement in health 14 Shavasana 10 min
related QoL and psychological well-being after yoga
15 Prayer 2 min
therapy.9
Practice duration 60 min
Though a few studies have been done on yoga and
COPD, the novelty of the present study is that it A total of 100 COPD patients were assessed for
throws light on improvements in QoL of the patients eligibility and then72 patients (mean age ± SD, 53.04 ±
and correlates it with the changes in lung function 9.71 years) who satisfied inclusion criteria were allocated
through adjuvant yoga therapy. to two groups by random selection and block allocation
(blocks of 4)/ Zelen’s design. Thirty six patients were
MATERIAL AND METHODS allocated to yoga group (22M and 14F with mean age of
52.12 ± 9.89 years) and received adjuvant yoga therapy
This prospective two-arm, single-blinded and in addition to medical management while 36 were
controlled study was undertaken as an interdisciplinary allocated to control group (20M and 16F with mean
collaborative work between the Centre for Yoga age of 53.97 ± 9.53 years) and received only medical
Therapy, Education and Research (CYTER) and management with no yoga therapy.
the department of Pulmonary Medicine, Mahatma
Gandhi Medical College and Research Institute In yoga group, four dropped out during study
(MGMC&RI), Puducherry. Approval was obtained period due to inconvenience and age factor and 32 of
from Institutional Research Council and Institutional them completed the four week yoga therapy. The study
Human Ethics Committee of Sri Balaji Vidyapeeth parameters were recorded in all the subjects before and
(P.G Dissertation/2017/05/77, 04/05/2017). The study after intervention of both groups.

118 SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018
 Soccalingam Artchoudane et al: Effectiveness of adjuvant yoga therapy in COPD

Table 2: Anthropometric parameters in yoga and control groups before (pre) and after (post) four weeks study period.
Yoga (n=32) Control (n=36)
Anthropometric
Parameters
Pre Post Pre Post

Height (cm) 158.62 ± 8.82 158.59 ± 8.79 161.50 ± 10.11 161.52 ± 10.10

Weight (kg) 63.66 ± 11.73 63.13 ± 11.43 62.72 ± 10.65 62.91 ± 10.87

BMI 25.43 ± 4.94 25.22 ± 4.79 24.06 ± 3.53 24.12 ± 3.56

Values are mean ± SD.

Anthropometric: BMI was calculated by Quetelet’s and the outcome variables were determined with
index, which is weight (kg)/height (m)2. correlations. P value less than 0.05 were considered
to indicate significant differences between the means.
Pulmonary Function: Forced vital capacity (FVC),
forced expiratory volume in first second (FEV1) and RESULTS
ratio of forced expiratory volume in first second to
forced vital capacity (FEV1/FVC) were measured using The anthropometric parameters of study participants
a standard computerized pulmonary function test before and after yoga therapy are given in Table 2.
‘Trueflow (ndd)’. The calibration is factory set and is Both groups were comparable at baseline with respect
not affected by temperature change, pressure change to anthropometric parameters, pulmonary functions
and condensation.10 and QoL.

Subject was seated comfortably in upright position Intra-group comparisons (Table 3): Changes in
with an erect spine, without bending forward. They pulmonary functions showed significantly better
were then instructed to take the disposable mouthpiece improvement of both FVC and FEV1 (p<0.001) among
inside their mouth with lips closed over it to avoid yoga group subjects after four weeks of yoga therapy.
leakage of air while blowing. It was repeated thrice There were significant negative changes in FVC and
with gap of 5 minute between each attempt subject FEV1 (p<0.001) among control group subjects after
encouraged to perform at their optimum level applying four weeks. However there was no significant change
maximal effort. The value of the best effort was then in FEV1/FVC in both the groups. In yoga group,the
considered for data analysis. percentage of changes were highly significant in FVC
and FEV1 (p<0.001).
QoL: Saint George Respiratory Questionnaire
(SGRQ) used for assessing COPD patients’ quality Changes in SGRQ showed significantly better
of life, as it is a disease-specific designed to measure improvement in all the QoL scores, namely symptoms
impact on overall health, daily life, and perceived well- score (p<0.001) and activity score (p<0.05), impacts
being in patients with obstructive airways disease.11 score (p<0.01) and quality score (p<0.001) among yoga
An excel-based scoring calculator was used for scoring group subjects after four weeks of yoga therapy. There
QoL variable symptoms score, activity score, impacts was no significant change in QoL score among control
score and QoL score. Changes in pulmonary function group subjects after four weeks.
parameters were recorded and correlated with QoL
(symptoms, activity, impacts and quality) scores of Intergroup comparisons (Table 3): There was highly
SGRQ. significant changes in both FVC and FEV1 (p<0.001)
in yoga group. FEV1/FVC showed no change between
Statistical Analysis: All data passed normality testing the groups. The % change showed highly significant
by Kolmogorov-Smirnov test. Hence intra-group change in both FVC and FEV1 (p<0.001) in yoga group.
comparisons of pre and post study data was done using
Student’s paired ‘t’ test while intergroup comparisons QoL score showed highly significant changes
between groups was done using Student’s unpaired ‘t’ (p<0.001) in all the scores of yoga group when compared
test. Relationships between baseline characteristics between groups. In yoga group, the % change was

SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018 119
 Soccalingam Artchoudane et al: Effectiveness of adjuvant yoga therapy in COPD

Table 3: Pulmonary function and quality of life parameters in yoga and control groups before (pre) and after(post) four weeks study period.
FVC: forced vital capacity, FEV1: forced expiratory volume in first second.

Yoga group (n=32) Control group (n=36)

Parameters
Pre Post % change Pre Post % change

Pulmonary
function

FVC (L) 1.99 ± 0.64 2.21 ± 0.50 ***, a 17.80 ± 30.75 a 1.96 ± 0.50 1.80 ± 0.51 *** -8.45 ± 12.90

FEV1 (L) 1.35 ± 0.49 1.61 ± 0.53 ***, a 24.75 ± 33.93 a 1.30 ± 0.51 1.18 ± 0.43 *** -6.47 ± 14.31

FEV1/FVC 0.66 ± 0.10 0.68 ± 0.12 2.82 ± 9.91 0.65 ± 0.15 0.66 ± 0.14 3.64 ± 22.63

QoL scores of
SGRQ

Symptoms score 51.74 ± 9.04 29.72 ± 6.86 ***, a -41.27 ± 14.50 a 49.74 ± 8.72 46.92 ± 6.00 -3.14 ± 19.71

Activity score 26.92 ± 9.26 22.43 ± 6.85 *, a -6.67 ± 43.41 a 24.79 ± 8.90 26.90 ± 4.29 19.68 ± 38.30

Impacts score 25.44 ± 9.24 21.37 ± 5.61 **, a -8.53 ± 32.88 a 29.65 ± 9.58 31.44 ± 7.65 11.15 ± 27.09

Quality score 26.73 ± 4.18 21.12 ± 5.96 ***, a -19.05 ± 26.16 a 24.09 ± 8.74 26.13 ± 6.18 15.12 ± 29.35

Values are mean ± SD. ***p< 0.001, ** p< 0.01, * p<0.05 by Student’s paired ‘t’ test for intra group comparison and
a
p<0.001by Student’s unpaired ‘t’ test for intergroup comparison.

highly significant in all the QoL scores (p<0.001), trend in adjuvant yoga therapy. Such findings could
namely symptoms score, quality score, activity score, become more significant and marked if the therapy
impacts scoreand quality score. was continued for a longer duration.

Correlation of pulmonary function and QoL The improvement in lung function coupled with
(Table 4): Significant correlation was found between decreased need for regular and rescue medicinal usage
pulmonary function and QoL in yoga group. FVC has been established using yoga as an adjunct therapy
correlated with symptoms score (r= -0.418, p<0.001), inCOPD.14,15
activity score (r= -0.257, p<0.05), and quality score (r=
-0.304, p<0.01). FEV1 correlated with FVC (r=0.882, At baseline, both groups were comparable and
p<0.001), symptoms score (r= -0.442, p<0.001), after study period there was significant improvement
quality score (r= -0.326, p<0.01), weight (r= -0.367, in FVC and FEV1 in yoga group. Reduction in FEV1
p<0.01) and BMI (r= -0.308, p<0.05). is directly correlated with impaired lung function.16
FEV1 increased significantly in yoga group and can
DISCUSSION be attributed to the comprehensive yoga therapy
package administered to the participants that may have
In the present study there was a marginal reduction produced marked improvement.
in body weight and body mass index of yoga group,
with a marginal increase in control group. This may be In this study we found that FVC increased
attributed to the practices utilizing excess fat deposited significantly in yoga group but reduced in control
peripherally and is in line with other studies attributing group as found in previous reports.2 NICE guidelines
improved metabolic function.12 It is also well known state that an increase of FEV1>1.5 L and in FVC >2.0
that an increase in BMI is associated with decreased L is correlated with greater changes in arterial blood
pulmonary function and decline in FEV1.13 Hence gases.17 Improvement in FEV1 and FVC may be
the trend towards reduction of BMI shows a healthy correlated with decreased airway resistance and better

120 SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018
 Soccalingam Artchoudane et al: Effectiveness of adjuvant yoga therapy in COPD

Table 4: Correlation of FVC with FEV1, symptoms, activity, impacts and quality scores of SGRQ in yoga (n=32) and control (n=36) groups
after four weeks study period.

Parameters FEV1 FVC SS AS IS QS Wt BMI

FVC 0.822 *** - -0.418 *** -0.257 * -0.133 -0.304 ** -0.167 -0.150

FEV1 - 0.822 *** -0.442 *** -0.151 -0.184 -0.326 ** -0.367 ** -0.308 *

Correlation is significant at *p<0.05, ** p<0.01, *** p< 0.001 level (2-tailed).

FVC – forced vital capacity; FEV1 – forced expiratory volume in first second; SS - symptoms score; AS - activity score; IS –
impact score; QS – quality score; Wt – weight.

lung compliance and such enhancing effects in yoga and improved exercise tolerance. Our results are
group may be attributed to the nonspecific broncho- consistent with other studies which reported related
protective or broncho-relaxing effect of yoga training as changes after yoga therapy in healthy volunteers as
postulated by Singh, along with the improved exercise well as in those suffering from different conditions.25,26
tolerance reported by Tandon following yoga therapy Our findings provide evidence for the scientific basis
in patients of COPD.18,19 This can also be correlated to of using yoga as an adjunct therapy in COPD with
the reports that well-performed slow yogic breathing significant improvement in pulmonary function and
maintains better blood oxygenation without increasing QoL indices.
ventilation, reduces sympathetic activation during
altitude-induced hypoxia and decreased chemoreflex We conclude that yoga has a positive and additive
sensitivity to hypoxia and hypercapnia.20,21 role as an adjuvant therapy along with standard medical
management of COPD. Results of this study reaffirm
Asthmatic patients showed a statistically significant that addition of such a complementary therapy improve
improvement in many lung parameters including FVC, physical condition by reducing weight and BMI while
FEV1 and QoL after 2 months of yoga practices and enhancing pulmonary function through parameters
Singh et al concluded that pranayama and yoga postures such as FVC and FEV1. It retarded the decline of
can be used to increase respiratory stamina, relax the pulmonary function that was seen in control group
chest muscles, expand the lungs, raise energy levels, only receiving medical management.
and calm the body.22
It is to be noted that adjuvant yoga therapy also
In the yoga group there was a significant significantly improved the qualitative aspects of the
improvement in activity score which implies that patient’s life through symptoms score, activity score,
patients were able to participate in more of the impacts score and total QoL score. As a form of therapy,
activities than earlier, which may be attributed to yoga is cost effective, relatively simple and carries
the improved vital capacity as well as enhanced minimal risk and we recommend that it can be advocated
self-confidence and self-reliance. Yogic counselling as an adjunct, complementary therapy in our search for
included dietary change and life style modification an integrated system of medicine capable of producing
which may improved significantly in impact score of health and well being in all. It is expected that the results
yoga group and the practice of pranayama resulted of this RCT will provide momentum for further in-depth
in overall improvement in QoL. Yoga group showed research in evaluating the efficacy of yoga in COPD
significant improvement in total quality score which patients. We recommend that yoga therapy can be safely
is similar to earlier reports that yogic breathing had advocated as an adjunct, complementary therapy in our
an overall positive effect on patients with moderate- search for an integrated system of medicine capable of
to-severe COPD.23,24 producing health and well being in all.

Pulmonary functions in COPD patients are The limitation of the study is that this has been done
compromised. Yoga therapy improved pulmonary on limited number of patients for only few weeks. More
function and quality of life by various mechanisms such studies with larger numbers of COPD patients
which include long time housework, carrying things and for a longer period of time may be done in future
upstairs, going out for entertainment and recreation to further validate such short term studies.

SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018 121
 Soccalingam Artchoudane et al: Effectiveness of adjuvant yoga therapy in COPD

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Pill reverses Type 2 diabetes

Researchers have engineered a material that temporarily coats the small intestine and reduces the amount of glucose
that enters the bloodstream during digestion. Scientists 'envision a pill' that 'mimics surgery' for people with
diabetes.
When they tested the material, which is called Luminal Coating of the Intestine (LuCI) on rats, they found that
it reduced "glucose response" by almost half. The research team developed the material because they want to find
a non-invasive treatment for reversing type 2 diabetes that is as effective as surgery. The intention is that once
swallowed, LuCI forms a temporary coating in the gut and then dissolves harmlessly a few hours later. The material
acted as a partial barrier to nutrient absorption, and prevented blood sugar "spikes" following a meal.
Source: Nature Materials. 2018 Jun 11:1

122 SBV Journal of Basic, Clinical and Applied Health Science - Volume 2 | Issue 3 | July - September 2018