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Effect of pranayama breathing technique on asthma control, pulmonary function, and quality of life: A single-blind, randomized, controlled trial
Complementary Therapies in Clinical Practice 38 (2020) 101081
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Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Effect of pranayama breathing technique on asthma control, pulmonary function, and quality of life: A single-blind, randomized, controlled trial☆ �an Yüce a, *, Sultan Tas¸cı b Gülyeter Erdog a b
Department of Aged Care, Nevsehir Haci Bektas Veli University, Nevsehir, Turkey Department of Internal Nursing, Erciyes University, Kayseri, Turkey
A R T I C L E I N F O
A B S T R A C T
Keywords: Asthma Asthma control Breathing exercise Quality of life Yoga
Objective: This study evaluated the effect of pranayama on asthma control, pulmonary function, and quality of life in people with asthma. Methods: Pranayama was applied to the pranayama group for 20 min once daily for 1 month, and relaxation was applied to the relaxation group similarly in addition to the standard treatment. The outcome measurement tools used were the Asthma Control Test (ACT), Asthma Quality of Life Questionnaire (AQLQ), pulmonary function test (PFT), and patient observation chart. Results: The pranayama group had significantly higher ACT score, overall AQLQ score, and subscale scores than the relaxation group (p < 0.05). However, there was no significant difference between the groups in terms of PFT parameters and peak expiratory flow values (p > 0.05). Conclusion: Pranayama improved asthma control and asthma-related quality of life in people with asthma, but it did not show a significant difference in PFT values.
1. Introduction Asthma is a common chronic disease of the respiratory tract involving chronic airway inflammation, bronchial hyperreactivity, and changeable airflow limitation. The prevalence of asthma, which affects approximately 300 million people worldwide, has increased rapidly in children and adults, particularly in industrialized countries, in the last 60 years [1,2]. Inappropriately and discontinuously controlled asthma symptoms negatively affect the quality of life of patients and prevent them from living a productive life [3,4]. For this reason, the main objectives of asthma treatment must be disease control and ensuring a better quality of life [4]. Because the normal progression of asthma continues with repeated attacks even with the administration of optimal drugs, there needs to be a multidimensional approach involving nonpharmacological strategies that help patients to cope better with asthma in disease management along with pharmacological treatment [1,5,6]. Therefore, currently, many patients with asthma resort to complementary and integrative applications (such as breathing techniques, yoga, herbal products, acupuncture, and homeopathy) for asthma treatment and
ameliorating their symptoms [7–10]. Yoga, a complementary and integrative method preferred by patients with asthma, has been learned and used in both Eastern and Western societies for years [11–14]. Yoga addressing the unification of the mind, body, and soul involves asana, pranayama, and meditation [11,12,15]. Pranayama, emphasized in classical texts and as an important part of yoga, has gained scientifically special attention. In Sanskrit, pranayama is translated as “breathing science, breath control, and breathing consciously.” Pranayama is the control and direction of energy in breathing in an organism to heal as well as maintain and enhance health [16–18]. Pranayama basically relies on the relationship among emo tions, cognition, and behavior [12,19–21]. Studies support that pra nayama can heal physical and mental health through the regulation of the relationship among the hypothalamus, hypophysis, adrenal gland, and sympathetic nervous system. Studies emphasize that regular pra nayama applications have positive effects on conditions such as chronic bronchitis, asthma, rhinitis, pharyngitis, obesity, diabetes, hyperten sion, insulin resistance, heart attack, allergy, anxiety disorders, and cancer [12,20–22]. Pranayama represents a simple self-control technique and involves
This study was registered under the Clinical Trials protocol registration system (NCT04110951) upon completion. The study was presented in 21st National Congress of Internal Medicine at 9–13 October 2019. * Corresponding author. E-mail addresses: [email protected] (G. Erdo� gan Yüce), [email protected] (S. Tas¸cı). ☆
https://doi.org/10.1016/j.ctcp.2019.101081 Received 18 October 2019; Received in revised form 6 December 2019; Accepted 17 December 2019 Available online 18 December 2019 1744-3881/© 2019 Elsevier Ltd. All rights reserved.
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
increasing an individual’s breath awareness [11,20,22]. Patients with asthma use their auxiliary breathing muscles more as a result of a decrease in chronic inflammation and expiratory air flow in chronic asthma. This causes air hunger in patients who then resort to limited, rapid, and shallow breathing through their mouth. These changes reduce breathing efficiency and deep breathing ability. In addition, respiratory distress causes high levels of distress, fear, and anxiety, particularly during asthma attacks. These dysfunctional breathing pat terns in asthma can worsen asthma symptoms [13,14,19,21]. Conscious breathing patterns are intended to replace these weak breathing patterns using pranayama [11,13,14,20,22]. Various techniques such as rap id/slow breathing techniques, deep breathing, diaphragm use, breath-holding sessions, nasal breathing, which are used to regulate the differentiation of the respiratory rate over time in pranayama, can help to maintain breathing more accurately and effectively and to thereby control asthma symptoms [11,20–22]. There are many studies related to the possible influences of pra nayama on some parameters such as asthma control, pulmonary func tion test (PFT), bronchodilator use, quality of life, and IgE and eosinophil counts [13,14,23]. These studies indicated that pranayama practiced regularly in addition to the standard pharmacological treat ment improves quality of life [24–26]; decreases inhaler bronchodilator use [19,27]; improves asthma symptoms/asthma control [25,27,28]; causes recoveries in breathing parameters such as forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, and peak expiratory flow (PEF) rate (PEFR) [24,29–36]; decreases airway sensi tivity [37]; increases respiratory muscle strength [38]; and decreases the number of absolute eosinophilia [33] in patients with asthma. Studies have reported that conventional parameters such as PFT parameters do not provide clear information on treatments and general conditions of patients, and there is a weak relationship between these parameters and tests that measure asthma control and quality of life [39–41]. However, most studies regarding pranayama have focused on the effects of the technique on breathing functions. There are a limited number of studies on the effect of this technique on asthma control and quality of life. Moreover, there is no consensus on which pranayama techniques to apply and application duration. Further, randomized, controlled studies with high levels of evidence regarding these tech niques have been suggested in these studies [24–38]. In this respect, the present study investigated the effect of pranayama on asthma control, breathing functions, and quality of life in people with asthma.
applications during the study period. Finally, a total of 50 patients completed the study (Fig. 1). The inclusion criteria were as follows: patients aged �18 years, those who could communicate, those with chronic asthma for 6 months diagnosed by doctors and undergoing treatment, those whose asthmas were not under control or partly under control in relation to the Global Initiative for Asthma values, those who were taking a beta2 agonist and/ or inhaling corticosteroid twice a week or more to control asthma symptoms, those without changes in inhaler bronchodilator drug po tions during the last 4 weeks, and those who could use a smartphone. Patients with severe asthma (predicted FEV1 � 60%); those with lung diseases such as COPD, tuberculosis, respiratory infection, diabetes, and coronary artery disease; those with smoking habit; pregnant/nursing mothers; those who exercised regularly; and those who benefited from other complementary and integrative health applications during treat ments were excluded from the study. All patients were informed about the purpose of the study, intervention strategies, patient rights, benefits, and possible risks in detail, and their consents were obtained. Those who wanted to quit, did not apply the breathing technique correctly, and did not participate in >15% of the applications were also excluded. 2.3. Randomization and blinding The patients were categorized in terms of age, sex, Asthma Quality of Life Questionnaire (AQLQ) scores, and Asthma Control Test (ACT) scores to ensure homogeneity in randomization after obtaining their pretest scores. Double blocks were formed according to the features of the categorized patients. The patients were enrolled in two groups with a 1:1 allocation ratio through simple random sampling: pranayama group in which pranayama was applied and relaxation group in which pro gressive relaxation was applied. After the first patient was selected using an opaque envelope with pranayama group written in it by a research assistant who did not participate in the study, the second patient who had similar features was automatically allocated to the other group. Sampling was maintained until the categories and blocks were equalized in both groups. After the first interview, each randomized patient was telephoned, and training was planned after making appointments. Thus, all patients were prevented from meeting and communicating with each other. The patients and the interviewer collecting post-test data were not informed about the study groups. 2.4. Defining sample size
2. Materials and methods
ACT scores were used to define the sample size of the study. ACT is composed of five questions, with the total score ranging between 5 and 25. The minimum clinically important difference is 3 points in ACT scores [1,2]. The minimum patient number to be included in the study was defined as 32, i.e., 16 patients in the pranayama group and 16 in the relaxation group. To find a 3-point difference in ACT scores, α-value of 0.05 and β-value of 0.20 were set as the conditions for analysis [42]. The study was maintained by conducting power analysis in connection with the data of the sample group during the study. When both groups reached 25 patients each, i.e., 50 patients in total, power analysis was repeated. Effect size was defined as 1.03, and study power was defined as 97% after power analysis by calculating the difference between ACT scores before and after the treatments and using the GPower 3.1 program.
2.1. Study design This study was conducted as a randomized, active-controlled, and single-blind study to reveal the effects of pranayama applied for 20 min once daily for 1 month on asthma control, pulmonary function, and quality of life in patients with asthma. 2.2. Participants and study setting This study was conducted at the chest diseases polyclinics of a public and a private hospital located at a province center in Turkey. Data collection continued from February 2018 to December 2018, and it was based on the Consolidated Standards of Reporting Trials guidelines. Participants were chosen among those who were diagnosed with asthma. All patients with asthma directed by polyclinic doctors were evaluated in terms of suitability for the study using a standardized checklist in preinterviews by researchers. A total of 102 patients with asthma were screened; among these, 81 patients were found to be suitable for the study, but 55 patients agreed to participate in the study. Patients were assigned to one of these groups: pranayama and relaxa tion. Two patients in the pranayama group and 3 in the relaxation group opted out because they could not spare time for the treatment
2.5. Outcome measurement tools 2.5.1. Asthma Control Test (ACT) ACT is composed of five main sections involving the frequency of shortness of breath as well as general asthma symptoms, use of rescue medications, effect of asthma on daily functioning, and overall selfassessment of asthma control. Patients were required to respond to each question with values between 1 and 5 (symptoms and activities: 1: 2
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
Fig. 1. The CONSORT chart of the study.
all the time and 5: not at all; asthma control rating: 1: not controlled at all and 5: completely controlled). The total score of these 5 questions ranges from 5 to 25 [1,2]. The form for which Turkish validity and reliability were performed was used in the study [43]. According to this form, the scores of patients are evaluated as follows: If the score is 25, it means that their asthma is “completely controlled”; if scores are be tween 24 and 20, it means that their asthma is “partly controlled”; and if scores are �19, it means that their asthma is “not controlled.” Cron bach’s α value of ACT was found to be 0.84 [43].
observed in FVC values at early stages of asthma in most patients. In most guidelines, the FEV1/FVC ratio is considered an airway obstruction criterion. FEV1 is used to define disease severity. PEF measurement is a type of test that can be performed through mobile handheld tools that enable patients to monitor their situations even at their homes for asthma diagnosis and treatment [46]. In PEF follow-up, the optimal PEF value is primarily defined because the follow-up of a patient is con ducted in terms of his/her optimal PEF value and not in terms of the predicted value obtained using spirometry [1,2].
2.5.2. Asthma Quality of Life Questionnaire (AQLQ) The standard AQLQ is a quality-of-life questionnaire specific to asthma comprising 32 questions [44]. The questionnaire evaluates re sponses using a 7-score scale (1: severely impaired; 7: not impaired at all) based on the asthma-related changes in the last 2 weeks. The stan dard AQLQ involves 12 questions about symptoms, 11 about activity limitation, 5 about emotional functions, and 4 about environmental stimuli. The mean values are calculated for subscale and overall scores. The mean value of the obtained scores is scored between 1 and 7. The minimum clinically acceptable score change is 0.50, and this change is called as “minimal significant difference” [45]. The questionnaire’s Turkish validity and reliability were determined. Cronbach’s α values were found to be 0.87 for symptoms, 0.87 for activity limitation, 0.83 for emotional functions, and 0.81 for environmental stimuli [45].
2.6. Intervention protocol A patient information form, ACT, and AQLQ were applied to both groups before treatment application during the first interview through face-to-face sessions, and the PFT values of the patients were recorded by the researchers. After 1 month of treatment application, ACT and AQLQ were administered to the participants by an interviewer who did not know to which groups the patients belonged. The patients under went PFT measurements, and their diaries were collected to record the data to their dossiers for evaluations. The PFT values of the patients before and after treatment application were recorded using the Zan 100 spirometer compatible with the American Thoracic Society/European Respiratory Society standards at the PFT laboratories of the study hos pitals. The patients were restrained from using short-acting bronchodi lators for at least 6 h and consuming food for at least 2 h before PFT. On the day of PFT measurement, the patients were asked to evacuate their bowels and bladders, and to rest for at least 15 min before recording. PFT was repeated thrice for each patient, and the optimal values were recorded. After the first interview, training sessions regarding asthma, drug use in asthma, armamentarium use of treatments, individual follow-up, and asthma management in emergencies were conducted for all participants. Additionally, individual PEF meters were distributed to all participants for self-monitoring their asthma controls. PEF measurement was explained and demonstrated to the participants. They were informed on
2.5.3. Pulmonary Function test (PFT) PFT has an important place in the diagnosis and follow-up of asthma. FEV1, measured during breathing function test and flow velocity determination, is the optimal indicator of airway obstruction in asthma. However, FEV1 reflects real airway obstruction only with powerful and maximal breathing effort because it is mostly related to breathing effort. The breathing effort-related portion of FVC reflects the condition of the airways, strength of the pulmonary expiratory muscles, and status of the lung elastic recession power. The FEV1/FVC ratio is an important final parameter for defining airway obstruction because no marked change is 3
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
performing PEF measurements twice a day, i.e., one before the tech nique in the morning and one before going to bed at night. Application diaries were distributed to all participants who completed training ses sions, and they were required to record their sessions, doses of relaxing inhaler drugs at emergencies, problems experienced during sessions, attack frequency, and PEF values on these diaries on a daily basis. The standard treatments of the participants were not intervened during the study. The participants were sent a phone message daily as a reminder to maintain their sessions regularly. Furthermore, the participants were called every week to discuss their problems regarding the technique applied, adaptation to the technique, weekly inhaler use, and attack frequency. The interview data were recorded on patient follow-up charts.
homogeneity of variances was analyzed using Levene’s test. Independent-samples t-test and Mann–Whitney U-test were used to compare the two groups. Paired-samples t-test and Wilcoxon’s pairedsamples test were used to evaluate repeated measurements in the same group. P-value of <0.05 was accepted as statistically significant in this study.
2.6.1. Pranayama group Kapalbhati (cleansing breath; rapid abdominal breathing), ujjayi (loud sound-producing pranayama), and anuloma viloma (alternate nostril breathing) were applied in the pranayama group by considering literature, expert views, and difficulty levels of applications. Within this scope, a 3-day applied training program was organized and a guide involving the steps of pranayama was created. The training program involved the use of nasal breathing incentive spirometer and diaphrag matic breathing in addition to teaching pranayama techniques (Ap pendix A). The pranayama group was trained by a researcher who had a yoga trainer certificate. Training sessions in the first meeting comprised 1-h theory and application, in the second meeting comprised 45-min application, and in the third meeting comprised 45-min application regarding pranayama in line with the training program planned be forehand. To ensure consistency in the breathing technique, the yoga instructor also recorded a video of the entire pranayama regimen, which lasted for approximately 20 min. After completing 3-day training and observations of the appropriate accomplishment of the applications, a pranayama video was downloaded to their smartphones, and a guide including the application steps was distributed. The participants were required to apply pranayama techniques in line with the video for 20 min once daily for 1 month.
3. Results
2.8. Ethical considerations The study protocol was conducted in full accordance with the Hel sinki Declaration of 1975 and approved by the Ethics Committee of the Nevs¸ehir Hacı Bektas¸ Veli University (Decree No: 2017.06.01). Written informed consent was obtained from all participants.
The descriptive features of the participants in both groups are pre sented in Table 1. There was no significant difference between the groups in this regard (p > 0.05). Distributions of ACT scores, AQLQ scores, and PFT values in the pranayama and relaxation groups before and after treatment application are presented in Table 2. Before treatment application, both groups were similar in terms of ACT scores (p > 0.05). However, the pranayama group had significantly higher ACT scores than the relaxation group after treatment application (p < 0.05). Moreover, a significant increase was observed in ACT scores of the two groups after treatment application (p < 0.05). There was no significant difference between the groups before and after treatment application in terms of FEV1, FVC, FEV1/FVC, and PEF (p > 0.05), but the mean PEF value of the pranayama group increased significantly after treatment application (p < 0.05). The mean values of the overall AQLQ and subscale scores of both groups before treatment application were found to be similar without any significant difference (p > 0.05). After treatment application, the Table 1 Descriptive features of the participants in the pranayama and relaxation groups.
2.6.2. Relaxation group Because there was no placebo breathing control treatment appro priate for yoga breathing technique in the literature, relaxation tech nique was applied in the second group to equalize the psychological effects of the treatment. Progressive relaxation was taught to the relaxation group during the same training span after literature review. Three days of applied training program and a relaxation technique application guide, including the steps of progressive relaxation tech nique, were prepared within this scope. Training sessions in the first meeting comprised 1-h theory and application, in the second meeting comprised 45-min application, and in the third meeting comprised 45min application regarding relaxation technique in line with the training program planned beforehand. After completing 3-day training and observations of the appropriate accomplishment of applications, a relaxing music to listen to during applications and a training video involving progressive relaxation directives were downloaded to their smartphones. Moreover, relaxation application guides involving the application steps were distributed to the participants. The participants were required to apply the relaxation technique in line with the video for 20 min once daily for 1 month.
Pranayama group (n ¼ 25)
Relaxation group (n ¼ 25)
Age (years) (Mean � SD) 42.1 � 14.51 45.6 � 12.52 Diagnosis time (year) 8.32 � 7.12 10.04 � 9.12 (Mean � SD) Number of attacks per 5.48 � 4.36 6.52 � 4.78 year (Mean � SD) Sex n (%) Females 22 (88.0) 23 (92.0) Males 3 (12.0) 2 (8.0) Education n (%) Primary school 12 (48.0) 20 (80.0) Secondary school 5 (20.0) 1 (4.0) High school 5 (20.0) 1 (4.0) University 3 (12.0) 3 (12.0) Marital status n (%) Married 19 (76.0) 20 (80.0) Single 6 (24.0) 5 (20.0) Family asthma story n (%) Yes 13 (52.0) 18 (72.0) No 12 (48.0) 7 (28.0) Allergy story n (%) Yes 9 (36.0) 12 (48.0) No 16 (64.0) 13 (52.0) Emergency service application for asthma in the last 3 months n (%) Yes 7 (28.0) 5 (20.0) No 18 (72.0) 20 (80.0) Use of rescue medications n (%) Yes 15 (60.0) 12 (48.0) No 10 (40.0) 13 (52.0)
2.7. Statistical analysis Data analysis was performed on ACT scores, PFT parameters, PEF values, and AQLQ scores. The IBM SPSS 22.0 statistics package program (IBM Corporation, Armonk, New York) was used for data evaluation. Chi-square test and Fisher’s exact test were used to evaluate the differ ence in terms of descriptive variables. Distribution of numerical values was analyzed with the Shapiro–Wilk normality test, and the
Note. SD: Standard deviation. a Obtained from the independent-samples t-test. b Obtained from the chi-square test. 4
p 0.358a 0.710a 0.380a 1.000b 0.110b
0.733b 0.145b 0.390b 0.508b 0.093b
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
Table 2 Comparison of changes in ACT, PFT, and AQLQ outcomes within and between the pranayama and relaxation groups. Pranayama group (n ¼ 25) Pretest
Posttest
Asthma Control Test 15.20 � 21.84 � (Mean � SD) 4.15 2.30 Pulmonary Function Tests (Mean � SD) 2.67 � 0.66 2.74 � 0.76 FEV1 (L) FVC (L) 3.20 � 0.79 3.24 � 0.90 FEV1/FVC (%) 82.60 � 83.84 � 7.91 5.92 PEF (mL/min) 394.40 � 415.60 � 108.82 119.27 Asthma Quality of life Questionnaire (Mean � SD) Symptoms 4.43 � 1.22 6.44 � 0.44 Activity limitation 4.11 � 0.88 6.07 � 0.69 Emotional function 4.70 � 1.50 6.60 � 0.57 Environmental stimuli 4.58 � 1.40 6.14 � 0.82 Total score 4.38 � 1.01 4.44 � 1.20
Within- group p-valuea
Relaxation group (n ¼ 25)
Within- group p-valuea
Pretest between groups p-valueb,c
Posttest between groups p-valueb,c
Pretest
Posttest
<0.001a
15.92 � 4.60
18.68 � 4.74
0.003a
0.564b
0.021c
0.886a 0.797a 0.352a
2.34 � 0.78 2.79 � 0.89 83.56 � 7.54 348.80 � 123.70
2.35 � 0.84 2.85 � 0.94 81.68 � 7.52 352.80 � 125.88
0.830a 0.333a 0.019a
0.119b 0.094b 0.502c
0.093b 0.146b 0.376c
0.290a
0.173b
0.080c
4.53 � 3.97 � 4.95 � 4.83 � 4.44 �
5.48 � 1.21 5.13 � 1.07 5.46 � 1.50 5.36 � 1.27 5.34 � 1.05
<0.001a <0.001a 0.043a 0.036a <0.001a
0.778b 0.645b 0.565b 0.586b 0.847b
0.001c 0.001c 0.001c 0.018c <0.001c
0.003a <0.001a <0.001a <0.001a <0.001a <0.001a
1.36 1.20 1.51 1.79 1.20
Note. SD: Standard deviation. FEV1: Forced expiratory volume in the first second. FVC: Forced vital capacity. FEV1/FVC: Tiffeneau–Pinelli index. PEF: Peak expiratory flow. Bold p values are statistically significant (<0.05). a Obtained from the Wilcoxon test. b Obtained from the independent-samples t-test. c Obtained from the Mann–Whitney U test.
pranayama group showed significantly higher overall AQLQ and sub scale scores than the relaxation group (p < 0.05). Moreover, both groups were found to have significantly higher overall AQLQ and subscale scores after treatment application (p < 0.05).
group [49]. The results of these studies supported that pranayama improved asthma control and decreased asthma symptoms. There was no significant difference between the present study groups in terms of FEV1, FVC, and FEV1/FVC values regarding asthma control. Contrary to these results, many studies have highlighted that pranayama positively affects PFT parameters. For example, Bhatt and Rampallivar investigated the effect of pranayama on the PFT parameters of patients with asthma. They showed that the FEV1, FVC, and FEV1/FVC values of the pranayama group increased significantly compared with the values of the control group after 3-month treatment application [50]. Sing et al. [24] and Sodhi et al. [30] showed similar results in their studies wherein the effects of yoga on patients with asthma was investigated. Vempati et al. [31] investigated the effect of yoga-based lifestyle on bronchial asthma control, whereas Gulati et al. [51] compared con ventional treatment and yoga application; they found that the FEV1 and FEV1/FVC values of the yoga group increased significantly compared with the values of the control group. Satyanand et al. [52] investigated the effect of two different pranayama techniques on the breathing functions of patients with asthma, whereas Hussein et al. [36] investi gated the effect of ujjayi pranayama in addition to diaphragmatic breathing exercise on asthma; it was revealed that the FEV1 and FVC values of the pranayama group improved profoundly compared with the values of the control group. In the study by Rizvi et al. comparing the effects of ayurvedic applications and yoga on patients with asthma, it was found that the FEV1 and FVC values of the yoga group increased significantly compared with the values of the Ayurveda and control groups [53]. There are many studies indicating that yoga results in an increase in PEFR values [54–57]. However, this study did not detect a significant difference between the groups in terms of their PEFR values. It must be noted that PFT values and asthma symptoms do not always correlate, and PFT values can be deficient in the evaluation of asthma [58,59]. In studies in which positive effects of pranayama on PFT and PEF values were found, it is seen that the application period was at least 2 months, and this duration could be up to 1 year. The contradictory results regarding PFT and PEF values in the present study can be linked to the short study duration. The AQLQ scores of the pranayama and control groups were found to be very low for all subscales before treatment application. However, after treatment application, AQLQ scores increased significantly in both groups, with the pranayama group having higher AQLQ scores than the relaxation group for all subscales. This study supports the results of
4. Discussion This study was conducted to (1) focus on the effect of pranayama on asthma control, breathing functions, and quality of life in people with asthma and (2) evaluate the effect of pranayama on asthma control in a detailed manner. The study results showed that pranayama improved asthma control and quality of life but did not result in a meaningful recovery of breathing functions. ACT scores, one of the study outcome for revealing the effect of pranayama on asthma control in this study, were found to be extremely low in both groups before treatment application, but the scores increased significantly in the pranayama group compared with those in the relaxation group after treatment application. Further, pranayama significantly improved asthma control in the pranayama group compared with that in the relaxation group. In a study, similar results were reported as reported by Karam et al. who investigated the effect of breathing techniques including pranayama on asthma control and quality of life as well as compared ACT scores before and after the breathing exercise program. The combined breathing exercises resulted in a meaningful increase in the ACT scores of patients with asthma [42]. Prem et al. evaluated asthma control in patients using an asthma control questionnaire in their study comparing the effect of Buteyko and pra nayama on patients with asthma. Symptom scores decreased in both Buteyko and pranayama groups although there was no meaningful dif ference between the groups [25]. Agarwal et al. evaluated the effect of pranayama on patients with asthma using St. George’s Respiratory Questionnaire and showed that symptom scores decreased significantly in the pranayama group after treatment application [32]. Murthy et al. obtained similar results in their study wherein they investigated the effect of pranayama exercises on bronchial asthma [47]. In their study evaluating yoga as a complementary treatment in asthma control, Kant and Agnihotri found that the yoga group had improved asthma symp toms (particularly daytime symptom scores) than the control group [48]. Mekonnen and Andualem investigated the clinical effects of yoga on asthma and reported that daytime and nocturnal asthma attacks relatively decreased in the yoga group compared with in the control 5
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
previous studies reporting improvements in the quality of life of patients with asthma after pranayama [24,26,51,57,60]. Kligler et al. reported that the overall AQLQ score, symptom, activity limitation, and emotional function subscale scores of the yoga group increased signifi cantly compared with the scores of the control group after treatment application [61]. Vempati et al. found that the yoga group had higher AQLQ scores for all subscales, except environmental stimuli, than the control group after treatment application in their study investigating the effect of yoga-based lifestyle on asthma control [31]. Sodhi et al. also reported similar results [30]. Prem et al. showed that the AQLQ overall, symptom, and activity limitation subscale scores increased profoundly in the pranayama group compared with the scores of the control group in the study comparing the effects of Buteyko and pranayama [25].
and to prolong the application duration. Moreover, inaccurate prior knowledge of the patients on yoga caused them to approach the effect of yoga application and its content suspiciously. Other limitations of the study are the patients who continued the applications themselves at their homes when the training process was completed and some patients who reduced the drug doses without consulting their doctors and re searchers after their asthma complaints decreased. Funding This study is associated with the PhD thesis “The Effect of Pranayama Breathing Technique on Asthma Control, Pulmonary Function, and Quality of Life.” This study was approved and financially supported by the Unit of Scientific Research Projects of Erciyes University (project number: TDK-2017-7652).
5. Conclusion In patients with asthma, pranayama applied for 20 min once daily for 1 month improved their asthma control and quality of life, and it did not cause a significant difference in PFT values. Further studies should be planned for >1 month to evaluate the longer-term effects of such practices.
Declaration of competing interest
6. Suggestions
�an Yüce: Conceptualization, Methodology, Formal Gülyeter Erdog analysis, Data curation, Investigation, Writing - original draft, Writing review & editing, Visualization. Sultan Tas¸ cı: Conceptualization, Methodology, Formal analysis, Investigation, Writing - review & editing, Project administration, Funding acquisition.
The research team has no conflicts of interest related to the study. CRediT authorship contribution statement
Extending the clinical use of pranayama as part of rehabilitation in the symptom control of asthma and longer observation studies to determine whether the positive effect of its application continues can be suggested in the study.
Acknowledgements
7. Limitations of the study
The authors wish to thank the academic member Prof. Dr. Ahmet € Oztürk of the Biostatistics Department, Erciyes University Medical Faculty, and all participants for their support and participation in this trial.
Some patients who met the inclusion criteria of the study lived far away from the province center, and this prevented repeated interviews and inclusion of more patients in the study. Moreover, maintaining the application daily made it difficult for the patients to follow the program
Appendix B. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.ctcp.2019.101081. Appendix A. Intervention Components of Pranayama Sessions Pranayama Training Program
Duration
Warm-up: All breathing practices are done in an upright seated position, with attention paid to a straight spine and shoulders drawn back. All inhales and exhales are done through the nose. Observe spontaneous breathing without controlling it in any way. Place the right hand on the abdomen just above the navel and the left hand over the center of the chest. The right hand will move up with inhalation and down with exhalation. There should be no tension in the abdomen. Try not to expand the chest or move the shoulders. Feel the abdomen expanding and contracting. Kapalbhati (rapid abdominal breathing): Inhale deeply through both nostrils, expanding the abdomen, and exhale with a forceful contraction of the abdominal muscles. The next inhalation takes place by passively allowing the abdominal muscles to expand. Inhalation should be a spontaneous or passive recoil, involving no effort. Perform five respirations to begin with. After completing five rapid breaths in succession, inhale and exhale deeply. This is one round. Practice three rounds with 30-s rest periods between rounds. Ujjayi (loud-sound-producing pranayama): Take awareness of the breath in the nostrils and allow the breathing to become calm and rhythmic. After some time, transfer the awareness to the throat. Try to feel or to imagine that the breath is being drawn in and out through the throat and not through the nostrils, as if inhalation and exhalation are taking place through a small hole in the throat. As the breathing becomes slower and deeper, gently contract the glottis so that a soft snoring sound like the breathing of a sleeping baby is produced in the throat. The sound of the breath should not be very loud. It should just be audible to the practitioner. If this is practiced correctly, there will be a simultaneous contraction of the abdomen. Both inhalation and exhalation should be long, deep, and controlled. Practice five repetitions per set with rest in between. Three sets of ujjayi are completed with 30-s rest periods between sets. Anuloma viloma (alternate nostril breathing): Close the right nostril and breathe in slowly through the left nostril for a count of 4. At the end of inhalation, close both nostrils and retain the air in the lungs for a count of 16. Open the right nostril, breathe in slightly through the right nostril and then slowly breathe out through the same nostril for a count of 8. The exhalation should be smooth and controlled. At the end of exhalation, immediately inhale through the right nostril for a count of 4, keeping the left nostril closed. Again, retain the breath for a count of 16 with both nostrils closed. Open the left nostril, breathe in slightly through the left nostril and then breathe out through the same nostril for a count of 8. This is one round. Practice five rounds. This protocol is repeated for three sets with 30-s rest periods between sets. Relaxation and rest: After the exercise, return the breath to normal and rest.
1–3 min
6
4 min
5 min
8 min
1–3 min
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Complementary Therapies in Clinical Practice 38 (2020) 101081
References
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7
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Effect of pranayama breathing technique on asthma control, pulmonary function, and quality of life: A single-blind, randomized, controlled trial☆ �an Yüce a, *, Sultan Tas¸cı b Gülyeter Erdog a b
Department of Aged Care, Nevsehir Haci Bektas Veli University, Nevsehir, Turkey Department of Internal Nursing, Erciyes University, Kayseri, Turkey
A R T I C L E I N F O
A B S T R A C T
Keywords: Asthma Asthma control Breathing exercise Quality of life Yoga
Objective: This study evaluated the effect of pranayama on asthma control, pulmonary function, and quality of life in people with asthma. Methods: Pranayama was applied to the pranayama group for 20 min once daily for 1 month, and relaxation was applied to the relaxation group similarly in addition to the standard treatment. The outcome measurement tools used were the Asthma Control Test (ACT), Asthma Quality of Life Questionnaire (AQLQ), pulmonary function test (PFT), and patient observation chart. Results: The pranayama group had significantly higher ACT score, overall AQLQ score, and subscale scores than the relaxation group (p < 0.05). However, there was no significant difference between the groups in terms of PFT parameters and peak expiratory flow values (p > 0.05). Conclusion: Pranayama improved asthma control and asthma-related quality of life in people with asthma, but it did not show a significant difference in PFT values.
1. Introduction Asthma is a common chronic disease of the respiratory tract involving chronic airway inflammation, bronchial hyperreactivity, and changeable airflow limitation. The prevalence of asthma, which affects approximately 300 million people worldwide, has increased rapidly in children and adults, particularly in industrialized countries, in the last 60 years [1,2]. Inappropriately and discontinuously controlled asthma symptoms negatively affect the quality of life of patients and prevent them from living a productive life [3,4]. For this reason, the main objectives of asthma treatment must be disease control and ensuring a better quality of life [4]. Because the normal progression of asthma continues with repeated attacks even with the administration of optimal drugs, there needs to be a multidimensional approach involving nonpharmacological strategies that help patients to cope better with asthma in disease management along with pharmacological treatment [1,5,6]. Therefore, currently, many patients with asthma resort to complementary and integrative applications (such as breathing techniques, yoga, herbal products, acupuncture, and homeopathy) for asthma treatment and
ameliorating their symptoms [7–10]. Yoga, a complementary and integrative method preferred by patients with asthma, has been learned and used in both Eastern and Western societies for years [11–14]. Yoga addressing the unification of the mind, body, and soul involves asana, pranayama, and meditation [11,12,15]. Pranayama, emphasized in classical texts and as an important part of yoga, has gained scientifically special attention. In Sanskrit, pranayama is translated as “breathing science, breath control, and breathing consciously.” Pranayama is the control and direction of energy in breathing in an organism to heal as well as maintain and enhance health [16–18]. Pranayama basically relies on the relationship among emo tions, cognition, and behavior [12,19–21]. Studies support that pra nayama can heal physical and mental health through the regulation of the relationship among the hypothalamus, hypophysis, adrenal gland, and sympathetic nervous system. Studies emphasize that regular pra nayama applications have positive effects on conditions such as chronic bronchitis, asthma, rhinitis, pharyngitis, obesity, diabetes, hyperten sion, insulin resistance, heart attack, allergy, anxiety disorders, and cancer [12,20–22]. Pranayama represents a simple self-control technique and involves
This study was registered under the Clinical Trials protocol registration system (NCT04110951) upon completion. The study was presented in 21st National Congress of Internal Medicine at 9–13 October 2019. * Corresponding author. E-mail addresses: [email protected] (G. Erdo� gan Yüce), [email protected] (S. Tas¸cı). ☆
https://doi.org/10.1016/j.ctcp.2019.101081 Received 18 October 2019; Received in revised form 6 December 2019; Accepted 17 December 2019 Available online 18 December 2019 1744-3881/© 2019 Elsevier Ltd. All rights reserved.
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Complementary Therapies in Clinical Practice 38 (2020) 101081
increasing an individual’s breath awareness [11,20,22]. Patients with asthma use their auxiliary breathing muscles more as a result of a decrease in chronic inflammation and expiratory air flow in chronic asthma. This causes air hunger in patients who then resort to limited, rapid, and shallow breathing through their mouth. These changes reduce breathing efficiency and deep breathing ability. In addition, respiratory distress causes high levels of distress, fear, and anxiety, particularly during asthma attacks. These dysfunctional breathing pat terns in asthma can worsen asthma symptoms [13,14,19,21]. Conscious breathing patterns are intended to replace these weak breathing patterns using pranayama [11,13,14,20,22]. Various techniques such as rap id/slow breathing techniques, deep breathing, diaphragm use, breath-holding sessions, nasal breathing, which are used to regulate the differentiation of the respiratory rate over time in pranayama, can help to maintain breathing more accurately and effectively and to thereby control asthma symptoms [11,20–22]. There are many studies related to the possible influences of pra nayama on some parameters such as asthma control, pulmonary func tion test (PFT), bronchodilator use, quality of life, and IgE and eosinophil counts [13,14,23]. These studies indicated that pranayama practiced regularly in addition to the standard pharmacological treat ment improves quality of life [24–26]; decreases inhaler bronchodilator use [19,27]; improves asthma symptoms/asthma control [25,27,28]; causes recoveries in breathing parameters such as forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, and peak expiratory flow (PEF) rate (PEFR) [24,29–36]; decreases airway sensi tivity [37]; increases respiratory muscle strength [38]; and decreases the number of absolute eosinophilia [33] in patients with asthma. Studies have reported that conventional parameters such as PFT parameters do not provide clear information on treatments and general conditions of patients, and there is a weak relationship between these parameters and tests that measure asthma control and quality of life [39–41]. However, most studies regarding pranayama have focused on the effects of the technique on breathing functions. There are a limited number of studies on the effect of this technique on asthma control and quality of life. Moreover, there is no consensus on which pranayama techniques to apply and application duration. Further, randomized, controlled studies with high levels of evidence regarding these tech niques have been suggested in these studies [24–38]. In this respect, the present study investigated the effect of pranayama on asthma control, breathing functions, and quality of life in people with asthma.
applications during the study period. Finally, a total of 50 patients completed the study (Fig. 1). The inclusion criteria were as follows: patients aged �18 years, those who could communicate, those with chronic asthma for 6 months diagnosed by doctors and undergoing treatment, those whose asthmas were not under control or partly under control in relation to the Global Initiative for Asthma values, those who were taking a beta2 agonist and/ or inhaling corticosteroid twice a week or more to control asthma symptoms, those without changes in inhaler bronchodilator drug po tions during the last 4 weeks, and those who could use a smartphone. Patients with severe asthma (predicted FEV1 � 60%); those with lung diseases such as COPD, tuberculosis, respiratory infection, diabetes, and coronary artery disease; those with smoking habit; pregnant/nursing mothers; those who exercised regularly; and those who benefited from other complementary and integrative health applications during treat ments were excluded from the study. All patients were informed about the purpose of the study, intervention strategies, patient rights, benefits, and possible risks in detail, and their consents were obtained. Those who wanted to quit, did not apply the breathing technique correctly, and did not participate in >15% of the applications were also excluded. 2.3. Randomization and blinding The patients were categorized in terms of age, sex, Asthma Quality of Life Questionnaire (AQLQ) scores, and Asthma Control Test (ACT) scores to ensure homogeneity in randomization after obtaining their pretest scores. Double blocks were formed according to the features of the categorized patients. The patients were enrolled in two groups with a 1:1 allocation ratio through simple random sampling: pranayama group in which pranayama was applied and relaxation group in which pro gressive relaxation was applied. After the first patient was selected using an opaque envelope with pranayama group written in it by a research assistant who did not participate in the study, the second patient who had similar features was automatically allocated to the other group. Sampling was maintained until the categories and blocks were equalized in both groups. After the first interview, each randomized patient was telephoned, and training was planned after making appointments. Thus, all patients were prevented from meeting and communicating with each other. The patients and the interviewer collecting post-test data were not informed about the study groups. 2.4. Defining sample size
2. Materials and methods
ACT scores were used to define the sample size of the study. ACT is composed of five questions, with the total score ranging between 5 and 25. The minimum clinically important difference is 3 points in ACT scores [1,2]. The minimum patient number to be included in the study was defined as 32, i.e., 16 patients in the pranayama group and 16 in the relaxation group. To find a 3-point difference in ACT scores, α-value of 0.05 and β-value of 0.20 were set as the conditions for analysis [42]. The study was maintained by conducting power analysis in connection with the data of the sample group during the study. When both groups reached 25 patients each, i.e., 50 patients in total, power analysis was repeated. Effect size was defined as 1.03, and study power was defined as 97% after power analysis by calculating the difference between ACT scores before and after the treatments and using the GPower 3.1 program.
2.1. Study design This study was conducted as a randomized, active-controlled, and single-blind study to reveal the effects of pranayama applied for 20 min once daily for 1 month on asthma control, pulmonary function, and quality of life in patients with asthma. 2.2. Participants and study setting This study was conducted at the chest diseases polyclinics of a public and a private hospital located at a province center in Turkey. Data collection continued from February 2018 to December 2018, and it was based on the Consolidated Standards of Reporting Trials guidelines. Participants were chosen among those who were diagnosed with asthma. All patients with asthma directed by polyclinic doctors were evaluated in terms of suitability for the study using a standardized checklist in preinterviews by researchers. A total of 102 patients with asthma were screened; among these, 81 patients were found to be suitable for the study, but 55 patients agreed to participate in the study. Patients were assigned to one of these groups: pranayama and relaxa tion. Two patients in the pranayama group and 3 in the relaxation group opted out because they could not spare time for the treatment
2.5. Outcome measurement tools 2.5.1. Asthma Control Test (ACT) ACT is composed of five main sections involving the frequency of shortness of breath as well as general asthma symptoms, use of rescue medications, effect of asthma on daily functioning, and overall selfassessment of asthma control. Patients were required to respond to each question with values between 1 and 5 (symptoms and activities: 1: 2
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Complementary Therapies in Clinical Practice 38 (2020) 101081
Fig. 1. The CONSORT chart of the study.
all the time and 5: not at all; asthma control rating: 1: not controlled at all and 5: completely controlled). The total score of these 5 questions ranges from 5 to 25 [1,2]. The form for which Turkish validity and reliability were performed was used in the study [43]. According to this form, the scores of patients are evaluated as follows: If the score is 25, it means that their asthma is “completely controlled”; if scores are be tween 24 and 20, it means that their asthma is “partly controlled”; and if scores are �19, it means that their asthma is “not controlled.” Cron bach’s α value of ACT was found to be 0.84 [43].
observed in FVC values at early stages of asthma in most patients. In most guidelines, the FEV1/FVC ratio is considered an airway obstruction criterion. FEV1 is used to define disease severity. PEF measurement is a type of test that can be performed through mobile handheld tools that enable patients to monitor their situations even at their homes for asthma diagnosis and treatment [46]. In PEF follow-up, the optimal PEF value is primarily defined because the follow-up of a patient is con ducted in terms of his/her optimal PEF value and not in terms of the predicted value obtained using spirometry [1,2].
2.5.2. Asthma Quality of Life Questionnaire (AQLQ) The standard AQLQ is a quality-of-life questionnaire specific to asthma comprising 32 questions [44]. The questionnaire evaluates re sponses using a 7-score scale (1: severely impaired; 7: not impaired at all) based on the asthma-related changes in the last 2 weeks. The stan dard AQLQ involves 12 questions about symptoms, 11 about activity limitation, 5 about emotional functions, and 4 about environmental stimuli. The mean values are calculated for subscale and overall scores. The mean value of the obtained scores is scored between 1 and 7. The minimum clinically acceptable score change is 0.50, and this change is called as “minimal significant difference” [45]. The questionnaire’s Turkish validity and reliability were determined. Cronbach’s α values were found to be 0.87 for symptoms, 0.87 for activity limitation, 0.83 for emotional functions, and 0.81 for environmental stimuli [45].
2.6. Intervention protocol A patient information form, ACT, and AQLQ were applied to both groups before treatment application during the first interview through face-to-face sessions, and the PFT values of the patients were recorded by the researchers. After 1 month of treatment application, ACT and AQLQ were administered to the participants by an interviewer who did not know to which groups the patients belonged. The patients under went PFT measurements, and their diaries were collected to record the data to their dossiers for evaluations. The PFT values of the patients before and after treatment application were recorded using the Zan 100 spirometer compatible with the American Thoracic Society/European Respiratory Society standards at the PFT laboratories of the study hos pitals. The patients were restrained from using short-acting bronchodi lators for at least 6 h and consuming food for at least 2 h before PFT. On the day of PFT measurement, the patients were asked to evacuate their bowels and bladders, and to rest for at least 15 min before recording. PFT was repeated thrice for each patient, and the optimal values were recorded. After the first interview, training sessions regarding asthma, drug use in asthma, armamentarium use of treatments, individual follow-up, and asthma management in emergencies were conducted for all participants. Additionally, individual PEF meters were distributed to all participants for self-monitoring their asthma controls. PEF measurement was explained and demonstrated to the participants. They were informed on
2.5.3. Pulmonary Function test (PFT) PFT has an important place in the diagnosis and follow-up of asthma. FEV1, measured during breathing function test and flow velocity determination, is the optimal indicator of airway obstruction in asthma. However, FEV1 reflects real airway obstruction only with powerful and maximal breathing effort because it is mostly related to breathing effort. The breathing effort-related portion of FVC reflects the condition of the airways, strength of the pulmonary expiratory muscles, and status of the lung elastic recession power. The FEV1/FVC ratio is an important final parameter for defining airway obstruction because no marked change is 3
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
performing PEF measurements twice a day, i.e., one before the tech nique in the morning and one before going to bed at night. Application diaries were distributed to all participants who completed training ses sions, and they were required to record their sessions, doses of relaxing inhaler drugs at emergencies, problems experienced during sessions, attack frequency, and PEF values on these diaries on a daily basis. The standard treatments of the participants were not intervened during the study. The participants were sent a phone message daily as a reminder to maintain their sessions regularly. Furthermore, the participants were called every week to discuss their problems regarding the technique applied, adaptation to the technique, weekly inhaler use, and attack frequency. The interview data were recorded on patient follow-up charts.
homogeneity of variances was analyzed using Levene’s test. Independent-samples t-test and Mann–Whitney U-test were used to compare the two groups. Paired-samples t-test and Wilcoxon’s pairedsamples test were used to evaluate repeated measurements in the same group. P-value of <0.05 was accepted as statistically significant in this study.
2.6.1. Pranayama group Kapalbhati (cleansing breath; rapid abdominal breathing), ujjayi (loud sound-producing pranayama), and anuloma viloma (alternate nostril breathing) were applied in the pranayama group by considering literature, expert views, and difficulty levels of applications. Within this scope, a 3-day applied training program was organized and a guide involving the steps of pranayama was created. The training program involved the use of nasal breathing incentive spirometer and diaphrag matic breathing in addition to teaching pranayama techniques (Ap pendix A). The pranayama group was trained by a researcher who had a yoga trainer certificate. Training sessions in the first meeting comprised 1-h theory and application, in the second meeting comprised 45-min application, and in the third meeting comprised 45-min application regarding pranayama in line with the training program planned be forehand. To ensure consistency in the breathing technique, the yoga instructor also recorded a video of the entire pranayama regimen, which lasted for approximately 20 min. After completing 3-day training and observations of the appropriate accomplishment of the applications, a pranayama video was downloaded to their smartphones, and a guide including the application steps was distributed. The participants were required to apply pranayama techniques in line with the video for 20 min once daily for 1 month.
3. Results
2.8. Ethical considerations The study protocol was conducted in full accordance with the Hel sinki Declaration of 1975 and approved by the Ethics Committee of the Nevs¸ehir Hacı Bektas¸ Veli University (Decree No: 2017.06.01). Written informed consent was obtained from all participants.
The descriptive features of the participants in both groups are pre sented in Table 1. There was no significant difference between the groups in this regard (p > 0.05). Distributions of ACT scores, AQLQ scores, and PFT values in the pranayama and relaxation groups before and after treatment application are presented in Table 2. Before treatment application, both groups were similar in terms of ACT scores (p > 0.05). However, the pranayama group had significantly higher ACT scores than the relaxation group after treatment application (p < 0.05). Moreover, a significant increase was observed in ACT scores of the two groups after treatment application (p < 0.05). There was no significant difference between the groups before and after treatment application in terms of FEV1, FVC, FEV1/FVC, and PEF (p > 0.05), but the mean PEF value of the pranayama group increased significantly after treatment application (p < 0.05). The mean values of the overall AQLQ and subscale scores of both groups before treatment application were found to be similar without any significant difference (p > 0.05). After treatment application, the Table 1 Descriptive features of the participants in the pranayama and relaxation groups.
2.6.2. Relaxation group Because there was no placebo breathing control treatment appro priate for yoga breathing technique in the literature, relaxation tech nique was applied in the second group to equalize the psychological effects of the treatment. Progressive relaxation was taught to the relaxation group during the same training span after literature review. Three days of applied training program and a relaxation technique application guide, including the steps of progressive relaxation tech nique, were prepared within this scope. Training sessions in the first meeting comprised 1-h theory and application, in the second meeting comprised 45-min application, and in the third meeting comprised 45min application regarding relaxation technique in line with the training program planned beforehand. After completing 3-day training and observations of the appropriate accomplishment of applications, a relaxing music to listen to during applications and a training video involving progressive relaxation directives were downloaded to their smartphones. Moreover, relaxation application guides involving the application steps were distributed to the participants. The participants were required to apply the relaxation technique in line with the video for 20 min once daily for 1 month.
Pranayama group (n ¼ 25)
Relaxation group (n ¼ 25)
Age (years) (Mean � SD) 42.1 � 14.51 45.6 � 12.52 Diagnosis time (year) 8.32 � 7.12 10.04 � 9.12 (Mean � SD) Number of attacks per 5.48 � 4.36 6.52 � 4.78 year (Mean � SD) Sex n (%) Females 22 (88.0) 23 (92.0) Males 3 (12.0) 2 (8.0) Education n (%) Primary school 12 (48.0) 20 (80.0) Secondary school 5 (20.0) 1 (4.0) High school 5 (20.0) 1 (4.0) University 3 (12.0) 3 (12.0) Marital status n (%) Married 19 (76.0) 20 (80.0) Single 6 (24.0) 5 (20.0) Family asthma story n (%) Yes 13 (52.0) 18 (72.0) No 12 (48.0) 7 (28.0) Allergy story n (%) Yes 9 (36.0) 12 (48.0) No 16 (64.0) 13 (52.0) Emergency service application for asthma in the last 3 months n (%) Yes 7 (28.0) 5 (20.0) No 18 (72.0) 20 (80.0) Use of rescue medications n (%) Yes 15 (60.0) 12 (48.0) No 10 (40.0) 13 (52.0)
2.7. Statistical analysis Data analysis was performed on ACT scores, PFT parameters, PEF values, and AQLQ scores. The IBM SPSS 22.0 statistics package program (IBM Corporation, Armonk, New York) was used for data evaluation. Chi-square test and Fisher’s exact test were used to evaluate the differ ence in terms of descriptive variables. Distribution of numerical values was analyzed with the Shapiro–Wilk normality test, and the
Note. SD: Standard deviation. a Obtained from the independent-samples t-test. b Obtained from the chi-square test. 4
p 0.358a 0.710a 0.380a 1.000b 0.110b
0.733b 0.145b 0.390b 0.508b 0.093b
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
Table 2 Comparison of changes in ACT, PFT, and AQLQ outcomes within and between the pranayama and relaxation groups. Pranayama group (n ¼ 25) Pretest
Posttest
Asthma Control Test 15.20 � 21.84 � (Mean � SD) 4.15 2.30 Pulmonary Function Tests (Mean � SD) 2.67 � 0.66 2.74 � 0.76 FEV1 (L) FVC (L) 3.20 � 0.79 3.24 � 0.90 FEV1/FVC (%) 82.60 � 83.84 � 7.91 5.92 PEF (mL/min) 394.40 � 415.60 � 108.82 119.27 Asthma Quality of life Questionnaire (Mean � SD) Symptoms 4.43 � 1.22 6.44 � 0.44 Activity limitation 4.11 � 0.88 6.07 � 0.69 Emotional function 4.70 � 1.50 6.60 � 0.57 Environmental stimuli 4.58 � 1.40 6.14 � 0.82 Total score 4.38 � 1.01 4.44 � 1.20
Within- group p-valuea
Relaxation group (n ¼ 25)
Within- group p-valuea
Pretest between groups p-valueb,c
Posttest between groups p-valueb,c
Pretest
Posttest
<0.001a
15.92 � 4.60
18.68 � 4.74
0.003a
0.564b
0.021c
0.886a 0.797a 0.352a
2.34 � 0.78 2.79 � 0.89 83.56 � 7.54 348.80 � 123.70
2.35 � 0.84 2.85 � 0.94 81.68 � 7.52 352.80 � 125.88
0.830a 0.333a 0.019a
0.119b 0.094b 0.502c
0.093b 0.146b 0.376c
0.290a
0.173b
0.080c
4.53 � 3.97 � 4.95 � 4.83 � 4.44 �
5.48 � 1.21 5.13 � 1.07 5.46 � 1.50 5.36 � 1.27 5.34 � 1.05
<0.001a <0.001a 0.043a 0.036a <0.001a
0.778b 0.645b 0.565b 0.586b 0.847b
0.001c 0.001c 0.001c 0.018c <0.001c
0.003a <0.001a <0.001a <0.001a <0.001a <0.001a
1.36 1.20 1.51 1.79 1.20
Note. SD: Standard deviation. FEV1: Forced expiratory volume in the first second. FVC: Forced vital capacity. FEV1/FVC: Tiffeneau–Pinelli index. PEF: Peak expiratory flow. Bold p values are statistically significant (<0.05). a Obtained from the Wilcoxon test. b Obtained from the independent-samples t-test. c Obtained from the Mann–Whitney U test.
pranayama group showed significantly higher overall AQLQ and sub scale scores than the relaxation group (p < 0.05). Moreover, both groups were found to have significantly higher overall AQLQ and subscale scores after treatment application (p < 0.05).
group [49]. The results of these studies supported that pranayama improved asthma control and decreased asthma symptoms. There was no significant difference between the present study groups in terms of FEV1, FVC, and FEV1/FVC values regarding asthma control. Contrary to these results, many studies have highlighted that pranayama positively affects PFT parameters. For example, Bhatt and Rampallivar investigated the effect of pranayama on the PFT parameters of patients with asthma. They showed that the FEV1, FVC, and FEV1/FVC values of the pranayama group increased significantly compared with the values of the control group after 3-month treatment application [50]. Sing et al. [24] and Sodhi et al. [30] showed similar results in their studies wherein the effects of yoga on patients with asthma was investigated. Vempati et al. [31] investigated the effect of yoga-based lifestyle on bronchial asthma control, whereas Gulati et al. [51] compared con ventional treatment and yoga application; they found that the FEV1 and FEV1/FVC values of the yoga group increased significantly compared with the values of the control group. Satyanand et al. [52] investigated the effect of two different pranayama techniques on the breathing functions of patients with asthma, whereas Hussein et al. [36] investi gated the effect of ujjayi pranayama in addition to diaphragmatic breathing exercise on asthma; it was revealed that the FEV1 and FVC values of the pranayama group improved profoundly compared with the values of the control group. In the study by Rizvi et al. comparing the effects of ayurvedic applications and yoga on patients with asthma, it was found that the FEV1 and FVC values of the yoga group increased significantly compared with the values of the Ayurveda and control groups [53]. There are many studies indicating that yoga results in an increase in PEFR values [54–57]. However, this study did not detect a significant difference between the groups in terms of their PEFR values. It must be noted that PFT values and asthma symptoms do not always correlate, and PFT values can be deficient in the evaluation of asthma [58,59]. In studies in which positive effects of pranayama on PFT and PEF values were found, it is seen that the application period was at least 2 months, and this duration could be up to 1 year. The contradictory results regarding PFT and PEF values in the present study can be linked to the short study duration. The AQLQ scores of the pranayama and control groups were found to be very low for all subscales before treatment application. However, after treatment application, AQLQ scores increased significantly in both groups, with the pranayama group having higher AQLQ scores than the relaxation group for all subscales. This study supports the results of
4. Discussion This study was conducted to (1) focus on the effect of pranayama on asthma control, breathing functions, and quality of life in people with asthma and (2) evaluate the effect of pranayama on asthma control in a detailed manner. The study results showed that pranayama improved asthma control and quality of life but did not result in a meaningful recovery of breathing functions. ACT scores, one of the study outcome for revealing the effect of pranayama on asthma control in this study, were found to be extremely low in both groups before treatment application, but the scores increased significantly in the pranayama group compared with those in the relaxation group after treatment application. Further, pranayama significantly improved asthma control in the pranayama group compared with that in the relaxation group. In a study, similar results were reported as reported by Karam et al. who investigated the effect of breathing techniques including pranayama on asthma control and quality of life as well as compared ACT scores before and after the breathing exercise program. The combined breathing exercises resulted in a meaningful increase in the ACT scores of patients with asthma [42]. Prem et al. evaluated asthma control in patients using an asthma control questionnaire in their study comparing the effect of Buteyko and pra nayama on patients with asthma. Symptom scores decreased in both Buteyko and pranayama groups although there was no meaningful dif ference between the groups [25]. Agarwal et al. evaluated the effect of pranayama on patients with asthma using St. George’s Respiratory Questionnaire and showed that symptom scores decreased significantly in the pranayama group after treatment application [32]. Murthy et al. obtained similar results in their study wherein they investigated the effect of pranayama exercises on bronchial asthma [47]. In their study evaluating yoga as a complementary treatment in asthma control, Kant and Agnihotri found that the yoga group had improved asthma symp toms (particularly daytime symptom scores) than the control group [48]. Mekonnen and Andualem investigated the clinical effects of yoga on asthma and reported that daytime and nocturnal asthma attacks relatively decreased in the yoga group compared with in the control 5
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
previous studies reporting improvements in the quality of life of patients with asthma after pranayama [24,26,51,57,60]. Kligler et al. reported that the overall AQLQ score, symptom, activity limitation, and emotional function subscale scores of the yoga group increased signifi cantly compared with the scores of the control group after treatment application [61]. Vempati et al. found that the yoga group had higher AQLQ scores for all subscales, except environmental stimuli, than the control group after treatment application in their study investigating the effect of yoga-based lifestyle on asthma control [31]. Sodhi et al. also reported similar results [30]. Prem et al. showed that the AQLQ overall, symptom, and activity limitation subscale scores increased profoundly in the pranayama group compared with the scores of the control group in the study comparing the effects of Buteyko and pranayama [25].
and to prolong the application duration. Moreover, inaccurate prior knowledge of the patients on yoga caused them to approach the effect of yoga application and its content suspiciously. Other limitations of the study are the patients who continued the applications themselves at their homes when the training process was completed and some patients who reduced the drug doses without consulting their doctors and re searchers after their asthma complaints decreased. Funding This study is associated with the PhD thesis “The Effect of Pranayama Breathing Technique on Asthma Control, Pulmonary Function, and Quality of Life.” This study was approved and financially supported by the Unit of Scientific Research Projects of Erciyes University (project number: TDK-2017-7652).
5. Conclusion In patients with asthma, pranayama applied for 20 min once daily for 1 month improved their asthma control and quality of life, and it did not cause a significant difference in PFT values. Further studies should be planned for >1 month to evaluate the longer-term effects of such practices.
Declaration of competing interest
6. Suggestions
�an Yüce: Conceptualization, Methodology, Formal Gülyeter Erdog analysis, Data curation, Investigation, Writing - original draft, Writing review & editing, Visualization. Sultan Tas¸ cı: Conceptualization, Methodology, Formal analysis, Investigation, Writing - review & editing, Project administration, Funding acquisition.
The research team has no conflicts of interest related to the study. CRediT authorship contribution statement
Extending the clinical use of pranayama as part of rehabilitation in the symptom control of asthma and longer observation studies to determine whether the positive effect of its application continues can be suggested in the study.
Acknowledgements
7. Limitations of the study
The authors wish to thank the academic member Prof. Dr. Ahmet € Oztürk of the Biostatistics Department, Erciyes University Medical Faculty, and all participants for their support and participation in this trial.
Some patients who met the inclusion criteria of the study lived far away from the province center, and this prevented repeated interviews and inclusion of more patients in the study. Moreover, maintaining the application daily made it difficult for the patients to follow the program
Appendix B. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.ctcp.2019.101081. Appendix A. Intervention Components of Pranayama Sessions Pranayama Training Program
Duration
Warm-up: All breathing practices are done in an upright seated position, with attention paid to a straight spine and shoulders drawn back. All inhales and exhales are done through the nose. Observe spontaneous breathing without controlling it in any way. Place the right hand on the abdomen just above the navel and the left hand over the center of the chest. The right hand will move up with inhalation and down with exhalation. There should be no tension in the abdomen. Try not to expand the chest or move the shoulders. Feel the abdomen expanding and contracting. Kapalbhati (rapid abdominal breathing): Inhale deeply through both nostrils, expanding the abdomen, and exhale with a forceful contraction of the abdominal muscles. The next inhalation takes place by passively allowing the abdominal muscles to expand. Inhalation should be a spontaneous or passive recoil, involving no effort. Perform five respirations to begin with. After completing five rapid breaths in succession, inhale and exhale deeply. This is one round. Practice three rounds with 30-s rest periods between rounds. Ujjayi (loud-sound-producing pranayama): Take awareness of the breath in the nostrils and allow the breathing to become calm and rhythmic. After some time, transfer the awareness to the throat. Try to feel or to imagine that the breath is being drawn in and out through the throat and not through the nostrils, as if inhalation and exhalation are taking place through a small hole in the throat. As the breathing becomes slower and deeper, gently contract the glottis so that a soft snoring sound like the breathing of a sleeping baby is produced in the throat. The sound of the breath should not be very loud. It should just be audible to the practitioner. If this is practiced correctly, there will be a simultaneous contraction of the abdomen. Both inhalation and exhalation should be long, deep, and controlled. Practice five repetitions per set with rest in between. Three sets of ujjayi are completed with 30-s rest periods between sets. Anuloma viloma (alternate nostril breathing): Close the right nostril and breathe in slowly through the left nostril for a count of 4. At the end of inhalation, close both nostrils and retain the air in the lungs for a count of 16. Open the right nostril, breathe in slightly through the right nostril and then slowly breathe out through the same nostril for a count of 8. The exhalation should be smooth and controlled. At the end of exhalation, immediately inhale through the right nostril for a count of 4, keeping the left nostril closed. Again, retain the breath for a count of 16 with both nostrils closed. Open the left nostril, breathe in slightly through the left nostril and then breathe out through the same nostril for a count of 8. This is one round. Practice five rounds. This protocol is repeated for three sets with 30-s rest periods between sets. Relaxation and rest: After the exercise, return the breath to normal and rest.
1–3 min
6
4 min
5 min
8 min
1–3 min
G. Erdo�gan Yüce and S. Tas¸cı
Complementary Therapies in Clinical Practice 38 (2020) 101081
References
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