Effect of specific yoga mudras on respiratory efficiency in asthma patients:

Introduction

Mudra means Gesture which may involve the whole body or simple hand position. It is a known fact that mudras help in communication. Mudras were also known to influence different body functions by enhancing connections with the cortex and influencing autonomic reflexes in these areas.1,2 The hand and the fingers, as they have numerous sensory receptors have a larger area of representation in the sensory (homunculus) cortex of brain. Pressure signals from fingers and hands stimulate corresponding areas of both cerebral cortex promoting cross lateralization and sensory motor integration.

Asthma is a chronic inflammatory disease of the airways with variable airflow obstruction characterized by recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night or in the early morning that is at least partially reversible either spontaneously or with treatment.3 Genetic determinants as well as environmental factors play a role in asthma. With increased severity and duration, airway remodeling occurs with smooth muscle hypertrophy, hyperplasia and mucous plugging resulting in fixed narrowing of the airway. Common precipitating factors for asthma include exercise, cold weather, exposure to air borne allergens and viral infections.

Asthma is also a stress related disorder.4 Stress by increasing the release of pro inflammatory cytokines precipitates asthma exacerbations. The inflammatory response is due to eosinophil infiltration, mast cell degranulation and lymphocyte activation resulting in airway hyper responsiveness. Both the components of Autonomic Nervous System (ANS) are essential for maintaining the airway caliber. Though there is no direct sympathetic innervation of the airway smooth muscle, stimulation α adrenergic receptors causes bronchoconstriction and stimulation of β2 receptors in bronchial smooth muscle causes bronchodilation. In asthma, bronchoconstriction and increased glandular secretion is caused by increased activity of parasympathetic nervous system. To combat this, sympathetic activity increases to release Neuropeptide Y (NPY) which in turn could inhibit the release of acetyl choline. But it fails in its objective, since in asthmatic patients NPY nerves are reduced and direct sympathetic innervation of airway is negligible.5 These evidences suggest that asthma is characterized by abnormalities of both the components of ANS. It is also hypothesized that as mudras create subtle connections with emotional areas of the brain, stress & related disorders could be reduced by balancing autonomic nervous system.

In asthma, airflow obstruction occurs mainly during expiration, unless the disease is very severe. Respiratory efficiency tests employed in this study are simple bed side tests which help to assess mainly expiratory function of lungs. PEFR is the maximum rate in liters per minute with which air is expelled with maximum force after a deep inspiration. This test is generally used to assess larger airway obstruction and the normal value is 350-600L/minute. PEFR value is considered almost equally important with respect to forced expiratory volume in one second (FEV1) for diagnosing asthma.6 Peak flow meter values are almost identical with the PEFR values obtained by computerized spirometry in asthma patients.7 Breath holding time serves as a screening test for obstructive lung diseases and it i s an index of onset and endurance of dyspnea. It also could be positively correlated with FEV1 and FVC in evaluating obstructive diseases.8

The overall of Prevalence of asthma in India is 2.05% in adults above 15 years.9 In spite of tremendous advances in medical treatment, morbidity and mortality still persists. Hence alternative non-pharmacological interventions like yogic pranayama techniques and meditation are tried to prevent or treat asthma along with chemotherapy.10

It is said that specific lung specific mudras or hand gestures can improve respiratory efficiency by producing Broncho dilatation and reducing mucous congestion.1 There were only few studies depicting the scientific importance of mudras on other systems.11,12 Since no other study has reported regarding this, present study was done to find out whether these yoga mudras really improve respiratory efficiency and if so, whether it can be used as an additive measure to treat asthma.

Aim & Objectives

To study the effect of specific Yoga Mudras on Respiratory Efficiency in Asthma patients.

Materials and Methods

The present interventional study was done in the department of Physiology of a private Medical College Hospital, Madurai after obtaining Institutional Ethical Clearance. Stable Asthma patients of both the genders, between the age groups of 20–50years, weight & height matched were enrolled for the study. Patients attending Respiratory Medicine O.P in July 2018 and hospital workers (especially housekeeping staff in the medical college campus) who were known asthmatics with disease duration of more than one year but not on routine drug treatment were included in the study. 50 asthma patients who were chosen randomly were assigned as control group (n=25) and study group (n=25) by using a randomization sequence generated in Microsoft Excel. Asthmatics were selected based on adult asthma questionnaire, hospital records & only patients with intermittent and mild persistent asthma were included.5 (WHO Global Initiative for Asthma guidelines 2006)

Patients with acute asthmatic exacerbations and not willing to participate were excluded from the study. Subjects with other types of lung diseases, mudra trained individuals, smokers, subjects with skeleto-muscular disorders, subjects suffering from cardiac diseases and on medication were also excluded.

Results

Discussion

In the study group, according to Table 2, there was a significant improvement in all the respiratory parameters immediately after 30 minutes of mudra practice except for the Sniders test (Table 5). No significant difference was observed in the control group for all the parameters (Table 1,Table 4)

As asthma is associated with expiratory difficulty, PEFR, Expiratory blast test, sniders test & respiratory endurance tests were mainly used to assess expiratory function. As decrease in PEFR indicates larger airway obstruction, the immediate improvement in PEFR value indicates the decrease in bronchoconstriction that had happened after mudra practice. An increase in the duration of breath holding time shows the decreased response of respiratory centers to CO2. An increase in BH allows air to move fast behind the secretions and also reduces res piratory rate (reduces dyspnea) by desensitizing CO2 response.14 Improvement in expiratory blast test and respiratory endurance test also indicates the decrease in bronchial smooth muscle tone and improved respiratory muscle efficiency.

In a study conducted by Nagarajan et al in 2017, out of 100 volunteers in 25-40 years age group who underwent mudra training for 2 months, 71 subjects agreed that they could feel the improvement in health after mudra training.11 In a previous study done on the immediate effect (after 15 minutes) of mudras on cardiovascular and neurological function in heart patients, a significant decrease in heart rate, systolic blood pressure, diastolic blood pressure and blood viscosity was observed. Coronary perfusion pressure, myocardial blood perfusion volume and brain tissue blood supply had increased.12

Large part of the motor cortex of the brain is dedicated to hand movements. Sensory nerves from the fingers occupy a larger area in the homunculus on the lateral side of the contra lateral hemisphere. In the present study, Mudra practice started with performing atmanjali mudra to bring calmness and breath control. Pressing two palms together in Namaste position stimulates nerve endings in the palms which has abundant sensory receptors. Pressure in right palm will stimulate the left cerebral hemisphere, whereas pressure in the left palm will stimulate the right hemisphere. Equivocal stimulation of both the cerebral hemispheres balances the activity of sympathetic and parasympathetic components of the autonomic nervous system. May be this could be the reason why we hold our both hands tightly when tensed.

MRI studies had postulated the connection between asthma and emotion, as it is a known fact that stress aggravates asthma by releasing inflammatory mediators. Along with increased inflammatory signals in the lung & airways with respect to allergens, there is also activation of emotional area of the brain i.e. anterior insular cortex.15 Asthma represents an imbalance of the autonomic nervous system. It was a recorded in earlier studies that fronto insular cortex (ventral anterior insula), anterior and midcingulate cortices constitute the cortical autonomic control centers which respond to emotional stimuli.16 Fronto insular cortex acts as afferent and anterior cingulated as efferent centers. Left hemisphere activation predominantly affects parasympathetic function and right hemisphere activation sympathetic function. It is understood from this that lung specific hand mudras could have modulated the autonomic function to reduce bronchoconstriction and inflammation.

Linga mudras were known to remove the phlegm in the body by increasing body temperature especially in asthmatics and not in normal subjects. To confirm this, for 3 new asthma patients, body temperature was recorded before and after 20 minutes of performing linga mudra alone. A 3º F rise in body temperature was recorded. This mudra could help in exercise induced asthma too, where hyperventilation leads to excess heat loss from the airway epithelium.17

Along with direct effect of mudras, focused attention & regulated breathing (slow & deep) during mudra practice could also have modulated the activity of the ANS.18 It is an established fact that circadian rhythm exists for bronchial muscle tone. Previous studies had noted significant circadian variation especially for PEFR both in normal and asthmatic individuals.19 Hence it was ensured that all the tests were performed only at specific time of the day between 10am-12pm.

Strength of the study

This study is the first of its kind to measure the airway changes in asthma patients using mudras.

The cooperation was very good from the patient’s side, as many showed interest in learning theses simple techniques eagerly which were easy to perform.

Limitation

Pulmonary function test parameters especially FEV1 & PEFR could have been measured with computerized spirometer. Results would have been better with larger sample size and with long duration practice. Future studies should evaluate the role of mudras in assessing the function of all the other organ systems in the body.

Conclusion

Lung specific hasta mudras significantly increased PEFR, BHT, EBT, RET immediately after 30 minutes of practice except for sniders test. No significant change was observed in the control group. This simple, easy to practice anytime, anywhere, cost effective technique must be practiced regularly to produce beneficial effects. When practiced along with pranayama, not only will they serve as an adjunct to chemotherapy but by reducing stress and balancing ANS can help to improve all the body functions.

Source of funding

None.

Conflict of interest

None.