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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 67-75

Comparative effect of chair calisthenics, Yoga, and chest physiotherapy on exercise tolerance, quality of life, and duration of hospital stay in hospitalized chronic obstructive pulmonary disease patients

1 Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
2 Department of Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission11-Apr-2019
Date of Acceptance16-May-2019
Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Peeyoosha Gurudut
Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.263248

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Aims: Previous studies have inferred that calisthenics, yoga, and chest physiotherapy (CPT) are effective in managing chronic obstructive pulmonary disease (COPD) patients. However, there are no studies done to compare calisthenics, yoga, and CPT. The aim of this study was to compare the effect of calisthenics exercises, yoga, and CPT on exercise tolerance, fatigue level, quality of life (QOL), and duration of hospital stay in COPD patients. Subjects and Methods: This study was an assessor-blinded, randomized, controlled trial. Data were collected from the inpatient department of a tertiary care hospital in Belagavi. Thirty-three patients diagnosed with COPD were divided randomly into calisthenics, yoga, and CPT groups. Outcomes were assessed for exercise tolerance, breathlessness, lung capacity, and QOL. Within-group analysis was done using the Wilcoxon signed-rank test/paired t-test. Between-group comparison was done using the ANOVA/Kruskal–Wallis test. Post hoc test was used to find which specific group was better than the others. Results: Between-group analyses showed that calisthenics was better than CPT (P < 0.001) to improve lung capacity, whereas calisthenics and yoga showed equal effect in improving lung capacity. Conclusions: Calisthenics, yoga, and CPT are equally effective in improving exercise tolerance, QOL, and perceived exertion. Calisthenics and yoga are equally effective and better than CPT in improving lung capacity of patients with COPD.

Keywords: Chronic obstructive pulmonary diseases, Exercise prescription, Hospital stay

How to cite this article:
Gurudut P, Ozha S, Passanha R, Patel S. Comparative effect of chair calisthenics, Yoga, and chest physiotherapy on exercise tolerance, quality of life, and duration of hospital stay in hospitalized chronic obstructive pulmonary disease patients. J Health Res Rev 2019;6:67-75

How to cite this URL:
Gurudut P, Ozha S, Passanha R, Patel S. Comparative effect of chair calisthenics, Yoga, and chest physiotherapy on exercise tolerance, quality of life, and duration of hospital stay in hospitalized chronic obstructive pulmonary disease patients. J Health Res Rev [serial online] 2019 [cited 2022 Jan 16];6:67-75. Available from: https://www.jhrr.org/text.asp?2019/6/2/67/263248

  Introduction Top

According to the WHO, 65 million people suffer from moderate-to-severe chronic obstructive pulmonary disease (COPD). In 2002, COPD was the fifth leading cause of death.[1] As per crude estimate, it is suggested that about 30 million people suffer from COPD in India. In the year 2002, COPD mortality was about 2.7 million deaths in India.[2] COPD includes the conditions, chronic bronchitis, and emphysema which can re-occur in the patient.[3]

The prevalence of COPD develops and progresses after the age of 40–50 years with both genders affected equally.[4] In India, the causes of COPD include tobacco/bidi smoking, exposure to indoor air pollution such as solid fuels used for cooking, outdoor air pollution, occupational chemicals and dusts, and frequent lower respiratory tract infections during childhood. Passive exposure to smoke and dust has also proved to cause of COPD.[5],[6]

Typical signs and symptoms of COPD patients include cough, expectoration, respiratory failure, and dyspnea, and as the disease progresses, even the daily activities become difficult.[5] These patients also have frequent exacerbations of symptoms that last from several days to few weeks which necessitate hospitalization of the patient with need of oxygen therapy (O2 therapy) further leading to decreased capacity to perform activities of daily living and exercise capacity.[7],[8] Several other studies have also shown that exercise tolerance in these patients is lower.[9],[10],[11] This fatigue along with dyspnea, in turn, affects their quality of life (QOL).[5] Hence, the assessment of COPD patients should include measures of airflow obstruction,[12] breathlessness,[13] exercise tolerance,[14] and QOL.[15]

Pulmonary function test remains mainstay investigation which is asked to be done by any respiratory physician for every patient with COPD.[16] According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), patients with COPD are classified into mild, moderate, severe, and very severe categories which are based on the findings of pulmonary function test.[3]

In spite of continued and regular medical management, COPD patients get acute exacerbation which requires hospitalization. During their inpatient stay along with medical management, pulmonary rehabilitation program aims at decreasing dyspnea and fatigue, improving exercise tolerance, and improving breathing capacity and respiratory function in patients with COPD.[17] These rehabilitation goals can be achieved by prescription of different forms of exercises. The recent guidelines for physiotherapy management of the adult and spontaneously breathing patient with COPD provide recommendation and guidelines for physiotherapy management in the form of chest physiotherapy (CPT).[18]

Apart from this, literature also suggests prescription of other forms of exercises such as aerobics, calisthenics, and yoga which have also been evaluated for their effects in COPD patients.[18],[19],[20] In spite of many studies and treatment approaches done on COPD, there are no comparative studies done to compare calisthenics, yoga, and CPT so as to find which of the three interventions prove to be superior to the others. There is a lack of high-level evidence (randomized controlled trials) where different forms of exercises have been compared with CPT.

The present study was conducted with an objective to compare the effect of calisthenics, yoga, and CPT on exercise tolerance, fatigue level, QOL, and duration of stay in the hospital in COPD patients.

  Subjects and Methods Top

The study design was an assessor-blinded, randomized, controlled clinical trial. The assessor was blinded from the treatment group to which the subject belonged. The participants' allocation was done by different researchers who also assigned participants to interventions. The interventions were administered by certified trainers who were blinded from their pre- and postintervention assessment data. To protect the rights of the participants, ethical clearance was obtained from the Institutional Ethical Committee (KLEUIPT/69/16/10/2017) and written informed consent was obtained from every participant of the study. The trial was registered with Clinical Trial Registry – India with registration number of CTRI/2018/03/012752.

Thirty-three patients with COPD admitted in a tertiary health-care center of Belagavi city were included in the study. The sample size was calculated using alpha-value from previous articles. A power analysis was conducted with 80% power at 95% confidence interval.[19],[20] After calculating the sample size of 33 with 11 in each group, the patients were randomly assigned to either calisthenics (CAL) group (n = 11), yoga (YG) group (n = 11), and CPT group (n = 11), and all the three groups underwent five sessions of intervention during the hospital stay.

The patients were included if they met the following criteria: (1) individuals hospitalized and diagnosed with COPD by a physician, (2) individuals of both genders between 40 and 70 years of age, and (3) those with mild-to-severe COPD according to the GOLD staging system.[3] Individuals were excluded if they presented with (1) unstable hemodynamic parameters, (2) when a patient is on O2 therapy, and (3) other comorbid factors and other systemic diseases.

Study protocol

After finding their suitability as per the inclusion and exclusion criteria, individuals were requested to participate in the study. Participants were briefed about the nature of the study and the intervention. The participants were allocated into three study groups randomly by lottery method. The participant was blindfolded to the codes and was asked to pick one chit and he was allocated to that specific group. Three study groups were as follows: chair calisthenics group (CAL group), yoga group (YG group), and CPT group. At the end of the study, there were no dropouts noted in any of the groups [Figure 1].
Figure 1: CONSORT flow chart

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Participants were assessed pre- and postintervention for endurance, dyspnea, lung capacity, and QOL using 6-min walk test for distance, modified Borg's perceived exertion scale, peak expiratory flow meter, and St. George's Respiratory Questionnaire (SGRQ-C), respectively.

Modified Borg's scale was used to assess symptoms of dyspnea/fatigue. This scale starts with 0 where there is no difficulty in breathing and progresses to 10 where the breathing difficulty is maximal. The patient was asked to mark his/her level of breathlessness according to the severity. This scale was found to be a valid and reliable assessment tool for dyspnea.[14]

The QOL was assessed in the study patients using SGRQ-C. This questionnaire consists of 14 questions. Patients were asked to complete the questionnaire as honestly as they can. The answer is that they feel best applies to them. The lowest possible is 0 and the highest is 100. Lesser the score, better the QOL. A total of all three component scores were calculated (symptoms, activity, and impacts) using the formula as stated.[15]

The endurance or exercise capacity was assessed using 6-min walk test for distance. This is a tool to measure physical endurance, which is the ability to maintain submaximal aerobic exercise for an extended time. The reliability for the 6-min walk test is 0.88 < r< 0.94 and convergent validity of the 6-min test is 71 < r< 0.82.[13]

Peak expiratory flow meter was used to assess airflow obstruction in the lung. It is an inexpensive, portable, and handheld device used for COPD patients, used to measure how well air flows in and out of the lung. The patient stands up straight, then takes a deep breath, and holds it till the mouthpiece is placed in between the teeth. Instruct the patient not to put the tongue against or inside the hole of the mouthpiece. The patient was asked to blow in the hole as fast and hard in a single blow. The first burst of air is the most important. The number was noted down, and the same procedure was repeated three times. The best of the three readings was the value used for the analysis.[12]

All the three interventions were given for a time period of 30–45 min for five sessions consecutively started after the patients were weaned from O2. The length of hospital stay was from the day of admission to the day of discharge. All participants were treated for 5 days from the day they were weaned from the O2 for 5 days consecutively irrespective of the length of hospital stay so that every patient is treated for equal number of days. [Table 1] provides the details of the exercises given to the study participants in the three study groups.
Table 1: Exercise interventions for the three study groups

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Statistical analysis of the present study was done using SSPS software version 21 (Belgaum Karnataka India) so as to verify the results obtained. Nominal data from participants' demographic details, i.e., age, duration of symptoms, and duration of hospital stay were analyzed using the ANOVA/Kruskal–Wallis test. Gender and GOLD staging were assessed for distribution in all the three study groups. Comparison of within-group changes, i.e., preintervention and postintervention changes on day 1, day 3, and day 5 was analyzed using the Wilcoxon signed-rank test/paired t-test for all the outcome measures. The between-group comparison for all the outcome measures was done using ANOVA/Kruskal–Wallis test based on whether the data were normally distributed. If the data analyzed were found to have a statistically significant difference between the three groups, data were subjected to post hoc test to find which specific group was better than the others.

  Results Top

[Table 1] provides the details of the exercises given to the study participants in the three study groups.

[Table 2] summarizes the characteristics of 33 participants who completed the study. For within-group analyses, the results indicate that there is a significant improvement of endurance in all the three groups on day 5 (P < 0.001). There was no significant difference found for modified Borg's scale on day 1, day 3, and day 5 postinterventions in all the three intervention groups, indicating no improvement in perceived exertion by participants in all the three intervention groups.
Table 2: Demographic profile

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Lung capacity assessed by peak expiratory flow meter showed improvement in calisthenics and yoga groups. However, CPT showed no improvement. QOL as assessed by SGRQ-C showed a statistically significant difference for all the three study groups (P = 0.0001), which was assessed only on day 1 and day 5.

When data were analyzed for between-group differences [Table 3], statistically significant results were observed only for peak flow meter. It was observed that there was a significant difference at day 1 postintervention (P = 0.023, F = 4.266) and day 5 postintervention (P = 0.009 and F = 9.416). When post hoc test was applied for multiple comparisons to assess for which group was better, on day 1 and day 5 postintervention calisthenics group was better than CPT (P = 0.023) [Table 4]. However, no significant difference was found between yoga and calisthenics groups (P > 0.05) and CPT and yoga groups (P > 0.05).
Table 3: Within-group analysis#

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Table 4: Between-group analysis#

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For exercise capacity, QOL, and dyspnea, the results indicate that all the three interventions were equally effective in treatment of patients with COPD.

  Discussion Top

COPD is a progressive disease; there is increased physical inactivity which has shown to be an important indicator of prognosis for mortality and morbidity in COPD patients.[21],[22],[23] Thus, pulmonary rehabilitation plays an important role in increasing physical performance, decreasing dyspnea, and improving QOL in COPD patients.[24],[25] According to the American College of Sports Medicine, patients with COPD should exercise regularly. The exercise program should include walking and strength training. With regular exercises, the patient can manage and delay the progression of the disease and live a better and productive life.[26]

In the present study, it was seen that more males suffered from COPD as compared to females. This predominance has been observed in many previous epidemiological studies of COPD population, which were conducted in India.[27] A study was to assess for the prevalence of COPD and observed that COPD occurrence was more in males (11.1%) as compared to females (4.5%). In Indian scenario, the predominance seen in males was attributed to factors such as smoking cigarettes and bidis, and in females, it was attributed to passive smoking, use of biomass fuels such as cow dung, and indoor air pollution.[28] In the present study, it was observed that most of the COPD participants were from rural areas with a mean age ranging between 57 and 60 years. Previous studies conducted have also shown similar age distribution. According to a systematic review and meta-analysis, adults aged ≥40 years suffer from COPD.[29]

Findings of the current study also showed no significant difference in the length of hospital stay among the three intervention groups. However, in the present study, there was no group where no exercise intervention was given. Inclusion of such a group would have given a clear picture on whether exercise prescription reduces the duration or length of hospital. Literature review revealed a single study to assess the length of hospital stay and functions with early mobilization using walking aids in hospitalized patients with acute exacerbation of COPD, which showed no significant reduction in hospital stay following the exercise program. This indicated prescription of exercise program does not reduce the length of hospital stay.[30]

Calisthenics is a form of exercise that includes stretching, strengthening, and aerobic exercises. A previous study included chair calisthenics exercises and assessed for peak O2 uptake; the author concluded that chair calisthenics is a low-intensity exercise which helps in improving endurance, dyspnea, and QOL.[19] Previous studies were done where calisthenics along with breathing exercises was given as intervention for COPD patients; the result of the studies demonstrated increased thoracic mobility which was attributed to reduction of dyspnea. The mechanism for this was thought to be desensitization of dyspnea through change in sensory feedback and proprioceptive receptor of the rib cage which, in turn, decreases the central nervous drive for O2. However, in the present study, there was an improvement in thoracic mobility but no significant reduction in dyspnea which could be due to short duration of time (five sessions). Literature suggests studies where calisthenics has reduced dyspnea and fatigue, thereby improving the QOL in COPD patients.[31],[32]

Yoga is a form of exercise which has been implemented in the treatment of patients with COPD. The findings of the present study indicate yoga to be an effective in improving endurance, lung capacity, and QOL by causing expansion of the lungs, and chest muscles are relaxed in turn increasing the strength of the respiratory muscles. Due to yogic training, there is a correction of abnormal breathing patterns and reducing muscle tension of inspiratory and expiratory muscles which promote bronchodilatation.[33],[34],[35],[36],[37],[38] Similar findings were noted by Katiyar and Bihari who observed improvement in QOL, lung function parameters, and reduced symptoms, and a patient had become more actively involved in their health care.[38] Yet, another study showed a significant improvement in peak expiratory flow rate reading at the end of intervention.[39] However, the present study did not show a significant improvement in perceived exertion and dyspnea which could be due to short duration of treatment, i.e., five sessions. In contrast to the finding of Ranjita et al., yoga has an effective method of reduction in breathlessness on modified Borg's scale. However, the above study included the intervention for 90 min/day and 6 days/week for 12 weeks and was done on coal miners with COPD, whereas in the present study, yoga was given immediately after weaning of O2 and was only given for five sessions.[40]

The CPT group in the present study demonstrated a significant improvement in terms of endurance and QOL, whereas no improvement was observed in perceived exertion and lung capacity. The changes in this study can be attributed to improvement in neuromuscular coordination, and rehabilitation exercises also help in desensitizing dyspnea perception which, in turn, leads to improvement in carrying out daily activities. Forward lean position helps in improving the functions of the diaphragm, reduces dyspnea, and decreases the activities of the rib cage muscle. Pursed lip breathing improves O2 saturation, helps recover the breathing pattern after exertion, reduces dyspnea, and decreases diaphragm activation. Airway clearance techniques such as Active Cycle of Breathing Technique have also been effective in improving lung capacity in COPD patients. In accordance with our study, the studies conducted in the past which have patient intervention demonstrated improvement in endurance and QOL. A study by Güell et al. showed that CPT in COPD patients has improved exercise tolerance and QOL, which was assessed using 6-min walk test and chronic respiratory questionnaire, respectively.[41] In a study done by Mador et al., Borg's scale measurement of dyspnea during exercise in patients with COPD did not show any significant change.[42]

The analysis of the result where comparison of the three study groups was done demonstrated mixed results where equal effectiveness was noted with all the three types of intervention in terms of exercise tolerance, dyspnea reduction, and better QOL, but for the lung capacity measure through peak expiratory flow, calisthenics group was better than CPT group. Further, no difference existed between calisthenics and yoga and yoga and CPT. This difference can be attributed to the nature of calisthenics exercises. Calisthenics exercises include continuous movement of the limbs which require more muscle work which in turn increases the need of O2 demand leading to increase in muscle strength and thoracic expansion, thus increasing the lung capacity. Calisthenics are more dynamic type of exercises which include the movements of all the limbs whereas, in comparison, CPT techniques are only targeted for the chest and rib cage, and the position of the patient is Semi-Fowler's. On the other hand, yoga is more of static postures and breathing control exercises which help in improving flexibility of the body and requires better breathing with lung capacity. A study Choudhary et al. concluded that yoga helps improving respiratory condition as compared to physical exercises.[43] However, this study was conducted for 3 months as compared to the present study. Another study also concluded that calisthenics as well as inspiratory muscle training is an effective way of improving inspiratory muscle strength and reducing dyspnea, but this study was done in 48 sessions over 4 months.[31] A study showed that calisthenics has improved forced expiratory volume in 1 s and reduced dyspnea and fatigue symptoms which, in turn, improved QOL and activities of daily living.[32]

The present study had few limitations. There was no ideal control group where no exercise prescription was given. The presence of such a control group would give a clear picture about the duration of hospital stay. The duration of intervention was very short, i.e., five sessions. This was kept short since the patients were to be treated only during their hospital stay. Patients were not followed up after discharge since most of the patients hailed from the rural areas.

The future scope of the study may include studies with longer duration of treatment with a control group where no exercise prescription would be given. Studies can also be conducted with pulmonary function test as their outcome measure. Combination of two forms of exercises can also be assessed for the effect.

  Conclusions Top

The findings of the present study indicated that low-intensity calisthenics, yoga, and CPT are equally effective in improving exercise capacity and QOL in patients diagnosed with COPD. However, chair calisthenics proved to be better than CPT in improving lung capacity by a peak flow meter, whereas yoga and calisthenics were equally effective. The patients with COPD when hospitalized should be intervened with mild intensity form of exercise that is dynamic in nature as soon as the patient is stable or weaned off oxygen therapy such as aerobic exercise or yoga postures.

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Conflicts of interest

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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