NIHR Signal Breathing exercises improve asthma and can be learned by DVD

Published on 7 November 2017

Breathing exercises taught by a physiotherapist in person or on DVD both improved the quality of life of adults with poorly controlled asthma to a small but similar extent. The DVD was the cheapest option, and it could lead to inexpensive internet delivery in the future.

This NIHR-funded trial recruited 655 UK adults with poorly controlled asthma. It showed about 63% of those receiving the breathing exercises had clinically important improvements in their asthma-related quality of life over a year, compared to 56% who improved receiving usual care.

Exercises did not improve formally measured lung function, suggesting the underlying biology of the asthma was unchanged.

The findings imply that breathing exercise programmes – currently recommended in the 2016 British guideline on the management of asthma when delivered by a physiotherapist – may be equally effective, and cheaper when delivered via DVD (or another video).

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Why was this study needed?

Asthma affects more than five million people in the UK and costs the NHS and social care (including disability payments) more than £1 billion each year. It led to at least 6.3 million primary care consultations, and 1160 asthma deaths in 2012.

While asthma medications can provide full symptom control for some, a recent European survey suggests this isn’t the case for most. Poorly controlled asthma can reduce a person’s quality of life and result in higher use of health services or time off work.

Many patients have concerns about taking medicines long-term, so non-drug approaches to control asthma, like practising breathing exercises at home, are of particular interest.

This trial aimed to provide new evidence on whether breathing exercises delivered by DVD or face-to-face by a physiotherapist were able to improve the lung function, number of attacks or the quality of life of adults with poorly controlled asthma.

What did this study do?

This randomised control trial recruited 655 UK adults with poorly controlled asthma who reported impaired asthma-related quality of life.

Participants were randomised to receive a breathing exercise intervention based on the Papworth method delivered via DVD (261 people) or face-to-face with a physiotherapist (132 people), or usual care (262 people).

The physiotherapy intervention involved three face-to-face respiratory physiotherapist sessions. The DVD intervention showed detailed explanations and illustrations of how to carry out the exercises, including a physiotherapist teaching the exercises to patients. Segments explaining the rationale for the exercises and addressing common doubts and concerns were also included. Usual care involved continuing to take normal asthma medications without further intervention.

Almost 95% of participants attended at least one of the three scheduled sessions with 93% attending all three. Similarly, engagement was good in the DVD arm.

What did it find?

  • Both the DVD and face-to-face physiotherapy sessions improved patient’s asthma-related quality of life scores over 12 months compared with usual care, though the difference was small. The proportion of patients showing a clinically important improvement in asthma-related quality of life score over one year (defined as a change in score of 0.5) was 62% in the DVD group and 64% in the physiotherapy group; both significantly higher than 56% for those receiving usual care.
  • The DVD was shown to be equally effective (non-inferior) as the physiotherapy sessions.
  • Costs for the physiotherapy face to face intervention was £83.45 per patient compared with £2.85 for the DVD (printing the discs and documentation).
  • Neither the DVD nor face-to-face physiotherapy sessions significantly improved lung function, airway inflammation or number of asthma attacks over the year. This suggests the interventions were improving patient-reported asthma symptoms without improving the underlying biology of the disease.

What does current guidance say on this issue?

The 2016 British guideline on the management of asthma states that breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.

What are the implications?

These simple exercises, which can be done at home, appear to be of modest benefit for adults who have poorly controlled asthma. The DVD option is appealing as it is cheap and just as effective as face-to-face training.

Technology is rapidly evolving so new internet delivery methods may now be available such as videos on websites, tablets and mobile apps, the researchers say they are investigating these. 

Citation and Funding

Thomas M, Bruton A, Little P, et al. A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults. Health Technol Assess. 2017;21(53):1-162.

This project was funded by the National Institute for Health Research Health Technology Assessment (project number 09/104/19).

Bibliography

NICE. Guidelines on asthma management. London: National Institute for Health and Care Excellence; 2017.

SIGN British guideline on the management of asthma. 153. Edinburgh: Scottish Intercollegiate Guidelines Network; 2016.

Why was this study needed?

Asthma affects more than five million people in the UK and costs the NHS and social care (including disability payments) more than £1 billion each year. It led to at least 6.3 million primary care consultations, and 1160 asthma deaths in 2012.

While asthma medications can provide full symptom control for some, a recent European survey suggests this isn’t the case for most. Poorly controlled asthma can reduce a person’s quality of life and result in higher use of health services or time off work.

Many patients have concerns about taking medicines long-term, so non-drug approaches to control asthma, like practising breathing exercises at home, are of particular interest.

This trial aimed to provide new evidence on whether breathing exercises delivered by DVD or face-to-face by a physiotherapist were able to improve the lung function, number of attacks or the quality of life of adults with poorly controlled asthma.

What did this study do?

This randomised control trial recruited 655 UK adults with poorly controlled asthma who reported impaired asthma-related quality of life.

Participants were randomised to receive a breathing exercise intervention based on the Papworth method delivered via DVD (261 people) or face-to-face with a physiotherapist (132 people), or usual care (262 people).

The physiotherapy intervention involved three face-to-face respiratory physiotherapist sessions. The DVD intervention showed detailed explanations and illustrations of how to carry out the exercises, including a physiotherapist teaching the exercises to patients. Segments explaining the rationale for the exercises and addressing common doubts and concerns were also included. Usual care involved continuing to take normal asthma medications without further intervention.

Almost 95% of participants attended at least one of the three scheduled sessions with 93% attending all three. Similarly, engagement was good in the DVD arm.

What did it find?

  • Both the DVD and face-to-face physiotherapy sessions improved patient’s asthma-related quality of life scores over 12 months compared with usual care, though the difference was small. The proportion of patients showing a clinically important improvement in asthma-related quality of life score over one year (defined as a change in score of 0.5) was 62% in the DVD group and 64% in the physiotherapy group; both significantly higher than 56% for those receiving usual care.
  • The DVD was shown to be equally effective (non-inferior) as the physiotherapy sessions.
  • Costs for the physiotherapy face to face intervention was £83.45 per patient compared with £2.85 for the DVD (printing the discs and documentation).
  • Neither the DVD nor face-to-face physiotherapy sessions significantly improved lung function, airway inflammation or number of asthma attacks over the year. This suggests the interventions were improving patient-reported asthma symptoms without improving the underlying biology of the disease.

What does current guidance say on this issue?

The 2016 British guideline on the management of asthma states that breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.

What are the implications?

These simple exercises, which can be done at home, appear to be of modest benefit for adults who have poorly controlled asthma. The DVD option is appealing as it is cheap and just as effective as face-to-face training.

Technology is rapidly evolving so new internet delivery methods may now be available such as videos on websites, tablets and mobile apps, the researchers say they are investigating these. 

Citation and Funding

Thomas M, Bruton A, Little P, et al. A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults. Health Technol Assess. 2017;21(53):1-162.

This project was funded by the National Institute for Health Research Health Technology Assessment (project number 09/104/19).

Bibliography

NICE. Guidelines on asthma management. London: National Institute for Health and Care Excellence; 2017.

SIGN British guideline on the management of asthma. 153. Edinburgh: Scottish Intercollegiate Guidelines Network; 2016.

A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults

Published on 25 September 2017

Thomas M, Bruton A, Little P, Holgate S, Lee A, Yardley L, George S, Raftery J, Versnel J, Price D, Pavord I, Djukanovic R, Moore M, Kirby S, Yao G, Zhu S, Arden-Close E, Thiruvothiyur M, Webley F, Stafford-Watson M, Dixon E & Taylor L

Health Technology Assessment Volume 21 Issue 53 , 2017

Background Asthma control is suboptimal, resulting in quality of life (QoL) impairment and costs. Breathing retraining exercises have evidence of effectiveness as adjuvant treatment, but are infrequently used. Objectives To transfer the contents of a brief (three-session) physiotherapist-delivered breathing retraining programme to a digital versatile disc (DVD) and booklet format; to compare the effectiveness of the self-guided intervention with that of ‘face-to-face’ physiotherapy and usual care for QoL and other asthma-related outcomes; to perform a health economic assessment of both interventions; and to perform a process evaluation using quantitative and qualitative methods. Design Parallel-group three-arm randomised controlled trial. Setting General practice surgeries in the UK. Participants In total, 655 adults currently receiving asthma treatment with impaired asthma-related QoL were randomly allocated to the DVD (n = 261), physiotherapist (n = 132) and control (usual care) (n = 262) arms in a 2 : 1 : 2 ratio. It was not possible to blind participants but data collection and analysis were performed blinded. Interventions Physiotherapy-based breathing retraining delivered through three ‘face-to-face’ respiratory physiotherapist sessions or a self-guided programme (DVD plus our theory-based behaviour change booklet) developed by the research team, with a control of usual care. Main outcome measures The primary outcome measure was asthma-specific QoL, measured using the Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included asthma symptom control [Asthma Control Questionnaire (ACQ)], psychological state [Hospital Anxiety and Depression Scale (HADS)], hyperventilation symptoms (Nijmegen questionnaire), generic QoL [EuroQol-5 Dimensions (EQ-5D)], assessments of airway physiology (spirometry) and inflammation (exhaled nitric oxide) and health resource use and costs. Assessments were carried out at baseline and at 3, 6 and 12 months post randomisation. Patient engagement and experience were also assessed using quantitative and qualitative methods. Results Primary efficacy analysis was between-group comparison of changes in AQLQ scores from baseline to 12 months in the intention-to-treat population with adjustments for prespecified covariates. Significant improvements occurred in the DVD group compared with the control group [adjusted mean difference 0.28, 95% confidence interval (CI) 0.11 to 0.44; p < 0.001] and in the face-to-face physiotherapy group compared with the control group (adjusted mean difference 0.24, 95% CI 0.04 to 0.44; p < 0.05), with equivalence between the DVD and the face-to-face physiotherapy groups (adjusted mean difference 0.04, 95% CI –0.16 to 0.24). In all sensitivity analyses, both interventions remained significantly superior to the control and equivalence between the interventions was maintained. In other questionnaire outcome measures and in the physiological measures assessed, there were no significant between-group differences. Process evaluations showed that participants engaged well with both of the active interventions, but that some participants in the DVD arm would have liked to receive tuition from a professional. Asthma health-care costs were lower in both intervention arms than in the control group, indicating ‘dominance’ for both of the interventions compared with the control, with lowest costs in the DVD arm. The rate of adverse events was lower in the DVD and face-to-face physiotherapy groups than in the control group. Conclusions Only 10% of the potentially eligible population responded to the study invitation. However, breathing retraining exercises improved QoL and reduced health-care costs in adults with asthma whose condition remains uncontrolled despite standard pharmacological therapy, were engaged with well by patients and can be delivered effectively as a self-guided intervention. The intervention should now be transferred to an internet-based platform and implementation studies performed. Interventions for younger patients should be developed and trialled. Funding This project was primarily funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 53. See the NIHR Journals Library website for further project information. Additional financial support was received from Comprehensive Local Research Networks.

The Papworth breathing technique is used by respiratory physiotherapists to control and correct breathing. The Papworth technique encourages gentler, more relaxed breathing using the abdomen rather than the chest.

Read more about the Papworth breathing technique.

Expert commentary

Asthma affects roughly 11% of the UK population and is largely managed through the regular use of inhaled anti-inflammatory drugs and short-acting drugs that open up the airways. However, adherence to these medicines is poor, and people often want to find additional ways to manage their symptoms.

This study of breathing exercises delivered via DVD resulted in a significant improvement in the quality of life at a reduced cost compared to usual care. Interestingly there were no improvements in any of the other outcomes that were measured including lung function, airway inflammation or asthma attacks.

Nevertheless, if these exercises can be delivered online at scale, this could be an attractive option for people trying to improve control of their asthma symptoms.

Samantha Walker, Director, Research & Policy; Deputy Chief Executive, Asthma UK

Expert commentary

In an innovative approach, Thomas et al., used a home-delivered DVD self-guide to provide breathing retraining to people with poorly controlled asthma and impaired quality of life.

The intervention was as effective at improving quality of life as breathing exercises taught in traditional face-to-face physiotherapy sessions.

A non-pharmacological approach is likely to appeal to many patients, and with a sustained effect size comparable to that achieved by long-acting beta-agonists, clinicians may consider this as a useful option. At the cost of only £2.85 per patient for the DVD and leaflet, healthcare commissioners and providers should be interested. Time to think about implementation?

Hilary Pinnock, Professor of Primary Care Respiratory Medicine, Asthma UK Centre for Applied Research, Allergy & Respiratory Research Group, Usher Institute of Population Health Sciences & Informatics, University of Edinburgh; General Practitioner, Whitstable Medical Practice

Categories

  •   Cardiovascular system disorders, Physical therapy