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DISCUSSION
Elsewhere (9-12) we have shown the significant benefits of this integrated approach of yoga therapy as compared to drug-only treatment in 53 pairs of bronchial asthmatics matched for age, sex, and type and severity of asthma who were followed up for 54 months. The results in Tables 2, 3, and 4 showing significant improvement in a large group of 570 patients is good confirming evidence for the usefulness of yoga in the management of asthma. Those who practiced yoga regularly obviously fared best. The group who discontinued yoga after varying periods of regular yoga practice have also shown significant improvements compared to the irregular group, indicating that the benefits of regular yoga practice are not merely short-term. Such regular practices must have brought about corrections at deeper levels that resulted in more permanent benefits. Thus, the integrated approach of yoga therapy appears to bring about substantial overall improvements in asthmatics.  Figure 1. Number of patients before and after yoga training in terms of PFR changes.
Note the shift of the cure to the right after yoga. df (f = 0.9) is the point of crossover.
Pathophysiology of bronchial asthma has been reviewed in detail by McFadden (17) and Scanlon (18). The two major factors that are recognizable today are the "extrinsic component" involving allergies to specific agents, and abnormalities of the Prostaglandin system and the autonomic nervous system (ANS), leading to markedly increased responsiveness of asthmatics' airways to smaller quantities of physical, chemical, and pharmacological stimuli. This is the "instrinsic defect". The hyperresponsiveness has been attributed to the ANS imbalance consisting of -
1. Preponderance of cyclic GMP over cyclic AMP in smooth muscles brought about by stimulation of the vagus nerve and thus the vagal receptors. This excessive vagal activity may emanate from stimulations of afferent receptors on the surface of airway smooth muscles, the latter initiating the afferent-efferent arc reflex.
2. Diminished responsiveness of bronchial beta2 receptors to the norepinephrine released from compensatory sympathetic stimulation of asthmatic stress, which in turn could be the effect of relative cortisol deficiency. This, then, could be due to increased levels of nor- epinephrine in the hypothalamus, thereby inhibiting corticotropin-releasing factor.
The integrated approach of yoga therapy appears to work at various levels in correcting the airway hyperresponsiveness.
Peripheral Level
1. Kriyas (cleansing techniques) used to desensitize the end receptors by systematic exposure to nonspecific graded irritants followed by deep relaxation may reduce the stimulation threshold of the vagal end receptors. Thus, the discharges in the afferent-efferent reflex arc may be reduced, resulting in normalizing the cyclic GMP and cyclic AMP balance in the bronchial smooth muscle.
2. Diminished responsiveness of beta2 receptors: It may be worthwhile to note here that yoga practices, particularly asanas and Pranayama, have been shown to increase the urinary ketogenic steroid (19) and plasma cortisol (20) levels. This increased blood level of cortisol may help to set right the beta receptor sensitivity mentioned above.
Central Effects
The stabilization of the entire nervous system brought about by deep relaxation and rest obtained through yogasanas may also reduce the discharge frequency in the ANS.
1. Scanlon has proposed that in asthma the increase in hypothalamic norepinephrine levels may inhibit the corticotropin-releasing factor, resulting in reduced cortisol levels. Yoga has been shown to reduce the norepinephrine levels in general, as evidenced by reduced urinary VMA levels (19, 20). It may be possible that yoga also reduces norepinephrine levels in the hypothalamus to correct the imbalances. Meditation, in particular, is beneficial in this context.
2. It has also been pointed out in the etiology of asthma that the emotional stress could increase the central vagal tone, increasing the efferent vagal discharges. Yoga, with its calming effect on the mind, can reduce and release the emotional stresses. The devotional sessions that help to harness the emotional upsurges are particularly useful in eliminating the emotional stresses. Analysis and proper perspective of one’s goals in life, along with the changes in attitude and life-style that are taught in our lecture sessions, contribute to improve psychological stamina.
Thus, we feel that this integrated approach of yoga practice, which is also recommended by others (1), may correct the basic pathophysiological disturbances in asthma at various levels to bring about the observed improvements.
This study is continuing with regular annual follow-up of these patients.
SUMMARY AND CONCLUSIONS
1. The effect of an integrated approach of yoga therapy on a group of 570 bronchial asthmatics was studied over 3 to 54 months.
2. The whole group was divided into three groups: regular and irregular yoga practitioners and those who discontinued.
3. The yoga training program lasted for 2 weeks (2 ½ hr daily) or 4 weeks (1 ¼ hr daily). The routine comprised breathing exercises, body loosening exercises, yogasanas, pranayama, and meditation, and a devotional session followed by a 3/4 hr lecture.
4. Subjective and objective data were collected before and after the training program using 30 parameters (18 specific and 12 general). Three groups of patients were identified, based on the regularity, irregularity, and discontinuation of yoga practice during the period of study.
5. Student's paired t test of significance for the mean of the differences has shown highly significant improvement in most of the specific parameters and in a few of the general parameters for the whole group.
6. The regular-practice group showed maximum improvements, the irregular group the least.
7. The medication analysis has shown that 69.2% of the patient's reduced or stopped oral medication; 66% have stopped or reduced cortisone, and 72.3% stopped or reduced injections.
8. The PFR analysis has shown significance in the regular and discontinued groups. The ratio Nf > 0.75/Nf < 0.75 increased from 27% before yoga to 49% after yoga, indicating movement toward normalcy.
These results clearly establish the efficacy of the integrated approach of yoga therapy in the treatment and rehabilitation of bronchial asthmatics.
Acknowledgments
We acknoledge with thanks Vivekananda Kendra (H.Q. Kanyakumari) for making this project possible. We also thank Dr. Subbukrishna of NIMHANS, Bangalore; Dr. Yeshonath of IISC, and Dr, Omprakash, Consultant, Chest Disease, for their help in statistical analysis and technical advice.
We place on record the continuous help rendered by Sri N. V. Raghuram, Smt. Vaidehi, and Smt. Subadra Devi and all the team of volunteers of Vivekananda Kendra who made this work take this shape.
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