Summary Points:

• Nonpharmacologic interventions, such as pulmonary rehabilitation are proven treatments for COPD.
• Recent studies have demonstrated that a supervised yoga program matches conventional COPD rehab (spirometry, function, QOL outcomes all similar).
• Unfortunately, patients aren’t using these therapies to their fullest extent.
• It’s important to overcome barriers so that patients can experience the potential benefits of these interventions.

Pulmonary rehabilitation has been proven to help improve symptoms (e.g., dyspnea, and fatigue), healthcare utilization, quality of life, and health status, including emotional well-being.[1,2]

Despite scientific evidence and support from clinical guidelines, however, nonpharmacologic interventions are persistently underutilized.[1,3-5] Even though potential challenges are likely multifactorial, it’s important to overcome these barriers so that patients can experience the full benefits of these effective interventions.

The benefits of exercise

It’s important that patients with COPD maintain physical activity and muscle strength. Pulmonary rehabilitation is a patient-centered, holistic, multidisciplinary program that can help achieve these goals.[1]

Patients who participate in these programs have been shown to improve their maximal exercise tolerance, peak oxygen uptake, endurance time during submaximal testing, functional walking distance, and peripheral and respiratory muscle strength.[2] However, the comprehensive design of a typical program doesn’t offer only exercise training, it also includes education, psychosocial and behavioral intervention, nutritional therapy, and outcome assessment.[2]

The American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society strongly recommend pulmonary rehabilitation for symptomatic patients who have severe COPD (FEV1<50% predicted). However, physicians may also consider the program for symptomatic or exercise-limited patients with an FEV1 >50% predicted.[3] Early referral will allow preventative strategies to be implemented sooner, plus greater flexibility in exercise training. Rehabilitation can be offered to both nonsmokers and smokers (although smoking cessation will clearly be an important component of the program).[2]

►A platform for success

For pulmonary rehab programs to be successful, they must be individually tailored. Every patient has a specific physio- and psychopathological impairment profile caused by the underlying disease and its associated morbidity. A patient’s symptoms, emotional state, understanding of the disease, cognitive and psychosocial functioning, and nutrition should be continually assessed throughout the program.[2]

Pulmonary rehab will be a challenge for patients who choose inactivity to avoid negative experiences. To overcome this, physiotherapists can take the following steps to help improve adherence and encourage success.[3]
• Build confidence early and provide a group dynamic. Confidence and group support are reportedly key factors that help patients complete a program. Patients may feel vulnerable because of their disease and lack motivation to participate based on misperceptions that they’re too sick to benefit from rehabilitation.
• Phyios should help patients understand that COPD is something that they could potentially manage effectively.
• Establish tangible goals. Positive results help motivate patients to stay in rehabilitation programs and finish them.
• Get patients mentally ready to participate in the program by alleviating their fears and concerns. For example, patients who are afraid of shortness of breath will not be mentally prepared for pulmonary rehab.
• Ensure patients are physically prepared by making sure they are free of acute illnesses, including minor ailments such as colds that may undermine their readiness.
• Help guarantee access to care by understanding whether a patient has any needs related to finances/reimbursement, transportation, and emotional support.

In a study published last year, Guo and colleagues recommended that in clinical practice, “professionals need to give patients some clues, time, space, and opportunity to identify and experience the advantages and benefits of exercise . . . people need to be introduced slowly to the idea of exercise (pulmonary rehabilitation). Most people need to see the advantages and benefits of a [pulmonary rehabilitation] program before they will consider starting and possibly completing a program.”[3] By understanding the obstacles patients face, physicians can develop strategies to help overcome these barriers and foster success.

►The maintenance challenge

Long-term effectiveness beyond about 2 years postrehabilitation is disappointing, highlighting the challenge of maintaining the benefits of pulmonary rehab. Both exacerbations of COPD and poor adherence to postrehab exercise programs are thought to contribute to this decrease in effectiveness. Therefore, the implementation of strategies that promote long-term adherence is essential for continuing success.[2]

Attempted strategies have included telephone contacts, monthly supervised reinforcement sessions, home-based exercise training, and recurrent rehab programs. Unfortunately, the most effective strategy has yet to be established.[4]

In this context, a holistic yoga program may oncrease compliance by shifting the focus from medicalised psychology of an outpatient program, to a health and wellbeing focused mind body exercise. There is good evidence that a supervised yoga program is as effective as conventional pulmonary rehabilitation for patients with stable chronic obstructive pulmonary disease (COPD). [5]

In a recent study [5], the 6-minute walk test, Borg dyspnea scale, and self-rated dyspnea all improved significantly from baseline to 12 weeks among patients who received yoga training (P=0.014 to P<0.001). The patients' mean C-reactive protein (CRP) level declined by 30%, suggesting decreased inflammation, and quality-of-life (QOL) outcomes all improved but not significantly so. In contrast, a conventional pulmonary rehabilitation program led to significant improvement only in one (QOL) parameter.

Between-group comparisons showed no significant differences for any of the outcomes,Randeep Guleria, MD, of the All India Institute of Medical Sciences in New Delhi, reported at CHEST 2015.
"Yoga is a cost-effective treatment and as effective as a standard pulmonary rehabilitation program," Guleria said."An optimum regimen, comprising supervised outpatient and home-based exercise, needs to be developed."

The results of the study suggest yoga could be an option for some patients, said discussion moderator Roger Goldstein, MD, of West Park Healthcare Center the University of Toronto. Moreover, culture differences that might have proven to be an obstacle to yoga as a COPD intervention have dissipated to a large extent.

"Just over the past 10 years or so…yoga instruction and participation have become more widely available and practiced. I think yoga could be a useful option for some patients with COPD.”

Yoga has been postulated as a potential aid to pulmonary rehabilitation. Anecdotal evidence and small, uncontrolled clinical evaluations hinted at a favorable effect of yoga on COPD outcomes, but the potential for yoga has remained unclear, Guleria said.

To conduct a controlled trial of yoga in COPD, Guleria and colleagues enrolled patients with stable COPD symptoms and randomly assigned them to a standard pulmonary rehabilitation program or to a program of supervised yoga exercises. None of the patients had experience with yoga exercises before participating in the study.

Prior to the study, the yoga instructor received information about COPD etiology, pathogenesis, and symptoms and developed exercises specific for the patient population, Guleria said.
Randomized intervention lasted for 12 weeks. In the yoga arm, patients attended 1-hour training classes twice a week for 4 weeks. Then they participated in supervised group exercise sessions every 2 weeks for 8 weeks. All patients kept a record of the date, time, and duration of exercises performed.

The yoga sessions adhered to core exercises: asanas (physical postures), pranayama (breathing technique), meditation, and shavasan (relaxation technique). The pulmonary rehabilitation program consisted of patient education, upper- and lower-limb exercise training, and breathing exercises.

The baseline evaluation for both intervention groups comprised assessments of lung function, severity of dyspnea (Borg and visual analog scales), 6-minute walk test, QOL, and the inflammatory markers CRP and interleukin (IL)-6. The evaluations were repeated after the 12-week interventions.
Investigators assigned 30 patients to each group. All but five of the patients were men, and the study group had a median age of 56, median COPD duration of 7.82 years, and median smoking index of 251.

The study population represented a mix of moderate (n=18), severe (n=25), and very severe (n=17) COPD. The most common comorbidity among the patients was hypertension (n=18), followed by diabetes (n=7), and coronary artery disease (n=5).
The yoga and conventional rehab groups did not differ significantly with respect to baseline spirometry parameters, 6-minute walk test, Borg dyspnea score, self-related dyspnea symptoms, baseline mean CRP value, or QOL. The yoga group had a significantly higher baseline mean IL-6 level (23.10 versus 6.65 pg/mL, P=0.001), which Guleria attributed to two patients with outlier values.

After 12 weeks of intervention, none of the spirometry parameters had improved significantly in either group (FEV1, FVC, FEV1/FVC, FEF 25-75, and PEFR).
However, dyspnea parameters all improved significantly in the yoga arm:
• 6-minute walk test: 419.0 to 456.6 feet (P=0.014)
• Borg scale: 1.5 to 1.0 (P<0.001)
• Visual analog rating of dyspnea symptoms: 55.17 versus 70.36 (P<0.001)

The mean CRP value decreased significantly in the yoga group (1.0 versus 0.70 mg/dL,P=0.007), but the mean IL-6 value unexpectedly increased (23.10 versus 32.74 pg/mL), an observation that Guleria said he could not explain.

With respect to QOL, none of the subscores changed significantly in the yoga arm (symptoms, activity, and impact), but all improved, as did the total score.

In the group that participated in conventional pulmonary rehabilitation, only the COPD impact score in the QOL assessment improved significantly (P=0.033).
The between-group comparisons showed no consistent trend favoring either intervention.

For more information on beginning a supervised yoga program for COPD, with registered physiotherapists, please visitwww.innerfocusphysio.com.au

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References:

1. Safka KA, McIvor RA. Non-pharmacological management of chronic obstructive pulmonary disease.Ulster Med J. 2015;84:13-21.

2. American Thoracic Society. Pulmonary rehabilitation.

3. Guo SE, Bruce A. Improving understanding of and adherence to pulmonary rehabilitation in patients with COPD: a qualitative inquiry of patient and health professional perspectives. PLoS One. 2014;9:e110835.

4. Corhay JL, Dang DN, Van Cauwenberge H, et al. Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy. Int J Chron Obstruct Pulmon Dis. 2014;9:27-39.

5. Guleria, R., Arora, S., Mohan, A., Kumar, G., & Kumar, A. (2015). Yoga Is as Effective as Standard Pulmonary Rehabilitation in Improving Dyspnea, Inflammatory Markers, and Quality of Life in Patients With COPD. CHEST Journal, 148(4_MeetingAbstracts), 907A-907A.