Evaluation of the Feasibility of a Home-Based TeleYoga Intervention in Participants with Both Chronic Obstructive Pulmonary Disease and Heart Failure

Abstract

Objective:

Test the feasibility and clinical outcomes of a home-based videoconferencing yoga intervention in participants diagnosed with both Chronic Obstructive Pulmonary Disease (COPD) and heart failure (HF).

Background:

Yoga has potential benefit for symptom relief in participants with COPD and with HF; however, functional impairment and transportation issues can hinder access to typical yoga classes.

Methods:

A controlled, nonrandomized trial was conducted of an 8-week TeleYoga intervention versus an educational control (information leaflets mailed to participants with one weekly phone call). One-hour TeleYoga classes were implemented twice weekly via multipoint videoconferencing, which connected participants to live classes via an Internet connection to their televisions.

Results:

Fourteen participants with COPD and HF took part in the pilot study (7 in the intervention group and 8 in the control). Intervention participants were adherent to classes, able to safely participate, and found the classes enjoyable after the 8-week program. Dyspnea after exercise improved in the intervention group.

Conclusions:

Despite their frailty, patients diagnosed with both COPD and HF were able to perform yoga safely in the home setting. TeleYoga was acceptable and adherence was good; however, technical issues were an important hindrance to participation.

Background

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are costly and burdensome chronic conditions that are increasing in prevalence worldwide.^1
–3 The conditions often coexist because of shared risk factors such as age and smoking. The prevalence of COPD in patients with a primary diagnosis of HF is estimated at 40%,⁴ while the prevalence of HF in patients with a primary diagnosis of COPD has been estimated at 21%.⁵ The combined diagnosis may not be readily appreciated because of similarities in clinical presentation, patient demographics, and comorbidities.⁶

Both COPD and HF are characterized by symptoms of breathlessness, limited exercise capacity, and skeletal muscle myopathy.⁶ The concurrent presence of these conditions can synergistically worsen exertional limitations compared to either diagnosis alone.^4,7 Yoga is a logical complementary therapy for patients with COPD and HF because of its emphasis on movement-coordinated breathing and low-impact fitness, both of which are thought to mechanistically improve dyspnea and consequently, physical function.^8
–10 Yoga is included in many pulmonary and cardiac rehabilitation exercises,^11,12 and the popular media extols the health benefits of yoga for people with chronic medical conditions.¹³

Traditional cardiac and pulmonary rehabilitation programs provide optimal monitoring and social support. They are focused on endurance and strength training. However, not all patients have insurance coverage for rehabilitation programs, long-term maintenance exercise after rehabilitation is not covered by insurance, and many communities do not have rehabilitation programs available. In addition, transportation to rehabilitation programs can be exhausting for patients with cardiopulmonary disease.

Previous research indicated that yoga was safe and feasible in participants with COPD and in those with HF.^9,10 In addition, yoga participants had greater improvements in symptoms and functional performance compared with usual care.^9,10 However, similar to cardiopulmonary rehabilitation, transportation to a central class location was a major barrier for participation in yoga classes in this older chronically ill population.⁹ Interventions to support participation in exercise-based programs such as yoga are needed for older and socially isolated adults, including those with chronic cardiopulmonary disease.

Recent advances in multipoint interactive videoconferencing technologies can enable individuals who are geographically isolated to participate in traditional group-based exercise programs from home.^14,15 The use of videoconferencing has been shown to be an effective tool to provide social support as well as behavioral interventions.^16,17 Successful implementation of a real-time home-based yoga program, TeleYoga, with live interaction between participants and a yoga teacher may provide convenience and potential for increased participation.

Therefore, the purpose of this study was to determine the feasibility and clinical outcomes of an 8-week home-based yoga program, conducted via simplified multipoint videoconferencing in a sample of patients with both COPD and HF. Feasibility was evaluated by adherence, safety, acceptability, and technical aspects of the TeleYoga intervention. Clinical outcomes included physical function, quality of life (QOL), and symptoms.

Methods

Study design and sample

In this quasiexperimental, nonrandomized study, an 8-week intervention of twice-weekly TeleYoga sessions was compared with an attention control group. A convenience sample of participants diagnosed with both COPD and HF was recruited. Letters describing the study were sent to patients with HF who also had COPD, according to the electronic medical record. Flyers and letters to pulmonary rehabilitation programs from the San Francisco Bay Area were also utilized for recruitment. In addition, participants from previous research studies of COPD and HF were sent recruitment letters. The study was registered with the ClinicalTrials.gov registry (NCT-02078739). Patients were not aware of which group they would be assigned to when they consented to the study (Fig. 1). The first seven patients were enrolled in the intervention group and the following eight in the control group.

FIG. 1.

CONSORT Flow Diagram.¹⁹

The study inclusion criteria were that participants (1) have provider-diagnosed COPD; (2) have provider permission for participation; (3) speak English; (4) be older than the age of 40 years; (5) have NYHA Class I-III systolic or diastolic HF; (6) have access to television and a broadband Internet connection; (7) have space to practice yoga at their home; and (8) be willing to have a research assistant connect videoconferencing equipment to their home television. Exclusion criteria included the following: (1) hospitalization within the 3 months before enrollment; (2) cognitive impairment as determined by a score of <3 on the Mini-Cog¹⁸; or (3) oxygen saturation <85% on 6 liters of nasal oxygen. Written informed consent was obtained from all participants before enrollment in the study. The study was approved by the University of California, San Francisco Institutional Review Board (12-08383).

Procedure

Potential participants who met screening criteria when they called the research office in response to recruitment were scheduled for a home visit. A home visit was conducted at baseline and again at 8 weeks by one of two registered nurses who served to enroll participants in the study. Pre- and postintervention physical assessments, study questionnaires, including the Mini-Cog to assess cognition, and installation or pick up of videoconferencing equipment were completed for the TeleYoga group during the home visits. Blinding to group assignment did not take place because the nurses were required to install or collect the TeleYoga DocBox during the home visit. Fidelity to data collection and intervention was addressed using a written protocol for data collection and intervention procedures. Participants were given $75 gift cards to Safeway grocery store at the conclusion of the study.

Participants were given their group assignment during the baseline visit, and those assigned to the TeleYoga group were provided a yoga mat, automatic blood pressure cuff, oximeter, and scale. They practiced taking their own blood pressure, weight, heart rate, and oxygen saturation levels during the baseline visit so that they could provide these data before the start of each yoga class. Participants in the Health Education control group were provided an orientation to the weekly mail and telephone contacts with the intervention nurse during their baseline home visit.

TeleYoga intervention

Participants reported their vital signs to the TeleYoga nurse before and after each yoga class. They were visually monitored for safety during each session by the TeleYoga nurse via the multipoint videoconferencing system interface. The TeleYoga nurse called each participant on the telephone before and after each TeleYoga session to assess symptoms of HF and COPD. Before participating in the TeleYoga study, participants provided contact information regarding their local emergency numbers and a nearby family/friend so that the TeleYoga nurse could activate emergency systems if she judged necessary. If vital signs were unstable (blood pressure <90 systolic, heart rate <50 beats per minute or oxygen saturation <90%) or if the participant had worsening symptoms of HF or COPD (increased dyspnea from baseline, edema, or orthopnea), the participant was stopped from engaging in the yoga class and referred to the healthcare provider.

TeleYoga classes were offered twice weekly for 8 weeks to participants in their homes using videoconferencing (methods previously described).²⁰ The yoga intervention was provided by the same certified yoga instructor/physical therapy assistant, with 8 years of experience in teaching yoga, throughout the study. Videoconferencing equipment was installed in the homes of the intervention group participants during the baseline home visit. The yoga protocol was based on the previously tested yoga programs for COPD^8,9 and HF,¹⁰ originally developed by a certified Iyengar yoga instructor with expertise in working with individuals living with chronic illness. In brief, postures included mountain, half down dog, cat, triangle, supported bridge, simple twist, staff, corpse, and cobbler poses, with postures modified as needed to meet the physical ability of each participant. Yoga classes were designed to integrate breathing exercises (slow breathing and extended exhalation breathing), imagery, meditation, and relaxation. Classes began with 10 min of relaxation followed by ∼35 min of poses and concluded with 15 min of meditation and relaxation.

Multipoint videoconferencing via DocBox technology (MicroDesign, Colchester, VT) was used to connect participants to live-streamed classes via an Internet connection to their televisions. Participants were instructed to turn on their televisions and then their DocBox, using one simple push button, to initiate the live streaming. A technician managed the live streaming remotely from the DocBox studio once the connection was made. All participants in the TeleYoga group participated at the same time. They could see the yoga teacher (and vice versa) and received personalized instruction, but could not see each other because of privacy concerns. If participants had questions, they raised their hands, and the technician would unmute them to talk with the yoga teacher. The TeleYoga nurse could see all participants and the yoga teacher and was connected by audio to the technician in the DocBox studio.

The DocBox technology was specifically chosen because it was designed for ease of use by older adults who may have no familiarity with technology. It is a hard drive box connected to the participant's television and remotely controlled by a technician. Once set up in the home and then settings adjusted by a technician, the participant turns on the TV and pushes one button on the hard drive box. After that, the remote technician can adjust the picture and sound as needed with no further technical skill required by the participant.

Control

Participants assigned to the attention control group received educational materials in the mail once per week for 8 weeks. The intervention nurse called each week for 15–30 min to discuss the educational information so as to provide an equal number of phone or mail contacts as in the intervention group. The education materials covered the following topics: evaluating health information, problems sleeping, elder abuse, flu vaccinations, accessing information about complementary and alternative therapies online, accessing information about medications online, depression, and a low sodium diet. The control group was designed to require 1 h of prereading before the nurse phone call and one-half to 1 h of nurse telephone contact per week.

Study feasibility

Adherence rates, safety factors, patient acceptability, and technical issues were used to assess study feasibility. Adherence was measured by the number of sessions attended and time spent in the TeleYoga classes. Safety was measured after each yoga session by the following: (1) dyspnea intensity and distress using the modified Borg scale,²¹ (2) heart rate, (3) percent oxygen saturation, and (4) number of emergency department visits. Participant acceptability was categorized as class enjoyment and class difficulty, assessed after each class using a scale from 0–10 and during a semistructured exit interview. Qualitative data were collected to assess participant perceptions of the yoga experience and are reported elsewhere.²⁰ Technical issues experienced by participants, TeleYoga nurse, yoga instructor, and technician during the yoga classes were logged during each class and categorized.

Clinical outcomes

Outcomes measured were physical function, QOL, and symptoms. Physical function was defined as muscle strength and endurance. Strength was tested via upper body (biceps) and lower body (quadriceps) testing using the total number of arm curls using two-pound hand weights and chair stands completed in 30 s. Endurance was measured with the home-adapted 6-min walk test that measured number of feet walked within 6 min.²² Validated QOL questionnaires included the St. George's Respiratory Questionnaire that is used for patients with COPD²³ and the Kansas City Cardiomyopathy Questionnaire (KCCQ) used for measurement in HF patients.²⁴ The St. George's Respiratory Questionnaire uses a scale of 0–100 with higher scores indicating more impairment and 4 unit changes signifying clinically important differences.²² The KCCQ uses a scale of 0–100 with higher scores indicating better QOL.

Symptoms of depression, dyspnea, and insomnia were evaluated at baseline and after study completion. Depression was evaluated using the validated Personal Health Questionnaire (PHQ)–8.²⁵ Scores of 10 and above indicate clinical depression. The PHQ-8 does not include a question related to suicidality as seen in the PHQ-9. Dyspnea was measured using the Dyspnea-12 questionnaire, a well-validated questionnaire used for patients with COPD,²⁶ and dyspnea and distress related to dyspnea were measured using the modified Borg scale²¹ at the end of the 6-min walk. Sleep was measured using the General Sleep Disturbance Scale and has been validated in many populations.^27,28

Analysis

All data were analyzed using SPSS statistical software version 19.0 (IBM Corp., Armonk, NY). All personal identifiers were deleted and the data were anonymized before data analysis. The authors compared characteristics of the intervention and usual care participant cohorts using Chi square for categorical variables and independent and paired t-test for continuous variables. The frequency distributions of the continuous variables were examined and were found to be approximately normal. Linear mixed modeling was used to analyze clinical outcomes before and after yoga classes. Alpha levels were preset at p < 0.05, and confidence intervals were set at 95% with data presented as means ± standard deviations wherever appropriate. Since this was a pilot study, the authors determined effect sizes for future sample size estimates.

Results

Fifteen participants took part in the pilot study with 7 from the intervention group and 8 from the attention control group (Fig. 1). They were recruited from past study participants (n = 2), Better Breathers groups (n = 5), response to mailing (n = 4), and referrals from colleagues (n = 4). Thirty-two were assessed for eligibility with 17 excluded for various reasons such as not meeting eligibility criteria or feeling too ill to participate. One attention control group participant dropped out of the study because of scheduling issues. There were no significant differences in baseline characteristics between the intervention and control groups (Table 1). The mean participant age was the early eighth decade (71 ± 8.5) with more females than males (n = 10, 66%). The participants were mostly Caucasian and college educated.

Table 1.

Sociodemographic, Clinical, and Psychologic Baseline Characteristics, N = 15

Variable	Yoga (n = 7)	Health education control (n = 8)	p
Age, years	73 ± 14.3	70.5 ± 2.7	0.66
Gender, female/male (n/n)	4/3	6/2	0.46
FVC, L (% predicted)	2.5 ± 0.6 (72 ± 26)	2.3 ± 0.8 (71 ± 17)	0.63
FEV₁, L (% predicted)	1.2 ± 0.5 (46 ± 22)	1.3 ± 0.8 (53 ± 25)	0.73
FEV₁/FVC ratio	0.50 ± 0.12	0.56 ± 0.20	0.45
GOLD classification (I/II/III/IV)	1/2/3/1	1/3/2/1	0.45
6 MW (feet)	704 ± 383	635 ± 298	0.71
DD-post	3.8 ± 4.0	1.9 ± 2.6	0.30
SOB- post	6.1 ± 2.2	3.9 ± 3.5	0.17
Educational level			0.41
Partial college or more	5	7
High school or less	0	1
Living situation			0.34
Live alone	4	4
With spouse	3	2
With family/friend	0	2
Oxygen use	5	4	0.41
Previous rehab attendance	5/2	4/4	0.40
Race, Caucasian	6	8	0.27
Current smoker	0	0	n/a
Smoking history (pk years)	42.3 ± 26.4	28.6 ± 21.9	0.33
NYHA classification			1.0
NYHA I	0	0
NYHA II	3	4
NYHA III	4	3
NYHA IV	0	0

Data are presented as mean ± Standard Deviation or n (%).

6MW, six-minute walk; DD, distress-related to dyspnea; FEV_1, forced expiratory volume in one second; FVC, forced vital capacity; GOLD, Global Initiative for Obstructive Lung Disease; L, liters; NYHA, New York Heart Association; pk yrs, pack years; SOB, shortness of breath.

Study feasibility

Adherence to the control group phone call intervention was 100%. Mean attendance was 14.5 (90%) of the yoga classes (out of 16 required classes). All participants attended the entirety of each class with the exception of the youngest participant who left 4 (of 13 attended) classes early because of personal/family scheduling reasons. Dyspnea intensity and distress related to dyspnea were rated a mean of 1.98 ± 1.52 (scale 0–10) and 0.22 ± 0.62 (scale 0–10), respectively, and averaged over all 16 class sessions (Fig. 2A). The mean participant heart rate stayed below 90 beats per minute (mean 83.5 ± 14.6) and mean oxygen saturation levels stayed above 90% (mean 95.2% ± 3.2) for all participants in all the yoga classes (Fig. 2B). There were no emergency department visits reported during the 8 weeks of class attendance. Class enjoyment was rated a mean of 8.3 ± 2.7 (scale 0–10) with the first class mean rated at 7.5 ± 2.7 and the final class mean of 9.0 ± 2.0. Mean class difficulty was 3.4 ± 2.6 (scale 0–10) with the first class mean rated at 5.3 ± 3.1 and the final class mean of 2.8 ± 2.5.

FIG. 2.

(A) Shortness of breath, distress-related to dyspnea, TeleYoga difficulty, and TeleYoga enjoyment over 16 class sessions. SOB, shortness of breath measured by modified Borg scale; Distress, distress-related to dyspnea measured by modified Borg scale; Difficulty and Enjoyment measured on 0–10 numerical rating scale. (B) Oximetry and heart rate over 16 TeleYoga sessions. Oxygen saturation is measured as a percentage; Heart rate is measured as beats per minute

Technical issues were categorized into four groups: Participant-related, nurse-related, yoga teacher-related, and IT support technical problems. Thirty-one yoga classes took place over 4 months. Participant-related problems took place in 14 (45%) classes. Participant issues ranged from problems logging into the class, frozen screens, visual lags, to firewall problems, but the most common problem was the login process that occurred in eight (26%) of the 31 classes. Nurse-related problems involved not fully visualizing the participant, delays in logging in, microphone issues, and poor streaming. The yoga teacher had only one technological problem that involved loss of audio (expired microphone battery). The IT support problems included distracting noises such as echoes and participants hearing other participants. There were only seven (23%) yoga classes without technical issues.

Clinical outcomes

Upper and lower body muscle strength, as well as the 6-min walk test score, did not significantly improve (Table 2). Following the 6-min walk test, shortness of breath and distress related to dyspnea significantly improved (p = 0.02, p = 0.03, respectively) in the intervention group compared with the control group. QOL measures improved in both groups, with no significant difference between groups. Although depression did not significantly improve, the overall depression scores in the intervention group improved while depression scores worsened in the control group (effect size −0.385). The overall dyspnea score did not significantly change. The General Sleep Disturbance Scale that measured insomnia improved in the intervention group and worsened in the attention control group. This score was not significant, but had a strong effect size (−0.937).

Table 2.

TeleYoga Outcomes

		Means (confidence interval)
	Time	TeleYoga	Health education	p	Effect size
Physical function
Arm curls (in 30 sec)	Baseline	14.7 (10.1–19.3)	14.5 (10.2–18.8)
Arm curls (in 30 sec)	8 weeks	16.9 (9.9–23.9)	19.2 (12.7–25.8)	0.47	−0.426
Chair stands (in 30 sec)	Baseline	10.1 (7.6–12.7)	8.4 (6.0–10.8)
Chair stands (in 30 sec)	8 weeks	13.3 (7.6–18.9)	12.1 (6.8–17.4)	0.82	−0.025
6 MW endurance distance (feet)	Baseline	704 (426–981)	635 (375–895)
6 MW endurance distance (feet)	8 weeks	751 (451–1052)	663 (381–945)	0.75	0.216
SOB end 6 MW	Baseline	6.1 (3.6–8.5)	3.9 (1.6–6.1)
SOB end 6 MW	8 weeks	2.8 (0–5.6)	4.3 (1.6–7.1)	0.02	−1.402
DD end 6 MW	Baseline	3.8 (1.1–6.5)	1.9 (0–4.4)
DD end 6 MW	8 weeks	0.5 (0–2.7)	2.4 (0.2–4.6)	0.03	−1.27
QOL
St Geo total ↓	Baseline	51.9 (36.2–67.6)	43.6 (28.8–58.5)
St Geo total ↓	8 weeks	55.1 (34.4–75.7)	44.3 (25.5–63.0)	0.74	0.242
St Geo impact ↓	Baseline	40.3 (21.0–59.7)	29.4 (10.9–48.0)
St Geo impact ↓	8 weeks	48.7 (26.0–71.4)	31.8 (11.6–52.1)	0.56	0.433
St Geo symptoms ↓	Baseline	60.9 (46.9–74.9)	40.4 (27.3–53.5)
St Geo symptoms ↓	8 weeks	56.6 (37.5–75.6)	41.5 (24.4–58.6)	0.58	−0.379
St Geo activities ↓	Baseline	71.1 (52.4–89.8)	68.6 (51.1–86.1)
St Geo activities ↓	8 weeks	64.7 (42.9–86.4)	67.4 (47.3–87.5)	0.3	−0.853
KCCQ ↑	Baseline	52.8 (33.3–72.3)	54.4 (37.5–71.4)
KCCQ ↑	8 weeks	56.7 (38.9–74.4)	61.4 (46.0–76.8)	0.46	−0.42
Symptoms
PHQ-8 ↓	Baseline	7.8 (3.3–12.3)	7.4 (3.5–11.3)
PHQ-8 ↓	8 weeks	7.2 (1.3–13.0)	8.6 (3.6–13.7)	0.48	−0.385
Dyspnea-12 ↓	Baseline	11.2 (2.5–19.8)	10.4 (2.9–17.9)
Dyspnea-12 ↓	8 weeks	10.7 (3.2–18.2)	10.8 (4.2–17.3)	0.79	−0.153
GSDS ↓	Baseline	47.7 (32.1–63.2)	48.4 (34.9–61.9)
GSDS ↓	8 weeks	40.5 (17.1–63.9)	62.8 (41.7–83.9)	0.09	−0.937

Arrow points in the preferred direction.

GSDS, general sleep disturbance scale; KCCQ, Kansas City cardiomyopathy questionnaire; PHQ-8, personal health questionnaire; St Geo, St. George's respiratory questionnaire; QOL, quality of life.

Discussion

This is the first study to provide preliminary evidence that a TeleYoga intervention may improve symptoms in participants with both COPD and HF who participated in a multipoint videoconference yoga program. More specifically, participants with COPD and HF were adherent to classes, able to safely participate, and found the classes enjoyable after an 8-week home-based yoga program. This pilot study was not powered to demonstrate effectiveness due to limitations of time and funding, and physical function measures did not significantly improve. However, dyspnea after exercise improved in the intervention group. Technical issues were an important hindrance to participation in the TeleYoga classes.

Feasibility in this study was evaluated by adherence, safety, acceptability, and technical aspects of the TeleYoga intervention. The adherence of the participants was high, similar to a study of patients with HF.¹⁰ In a study of yoga for patients with COPD,⁹ transportation issues were a significant barrier to participation. The authors found that Internet-based TeleYoga classes accessed at home were well attended in this older population with a dual COPD-HF diagnosis who were highly symptomatic.

The finding that a yoga program is safe is consistent with prior studies of yoga in separate COPD and HF populations.^9,10 In a meta-analysis of safety in all available randomized controlled trials of yoga interventions (94 studies), yoga was found to be as safe as usual care with an exercise intervention.²⁹ The authors concluded that recommending yoga to healthy or chronically ill adults should not be discouraged on the basis of safety.

Although technology provides an exciting opportunity for home-based exercise, the authors were unable to find other reports of home-based exercise studies that describe the technical issues in detail. The authors suspect that many Internet-based projects have been conceived but not completed because of the technical barriers involved. They found that the most common technical issue was the log-in process, with delays in connecting to the server and the technical support person who coordinated the audio and visual aspects of the class. In addition, the authors had ongoing problems with frozen screens, and several participants learned to continue the yoga practice without the full benefit of the teacher's feedback and interaction during class when their screens were frozen. The technical challenges with older, income-restricted adults were related to slow Internet access, older age televisions, and lack of basic technical understanding. There is a perception that currently available, real-time conferencing technology can easily be used for a project such as this. The one-button login process, access to TV rather than computer screen, and remote coordination of all functions after initial login were very attractive features of the DocBox system.^15,30 However, older home equipment prevented the optimization of the DocBox system and contributed to many unforeseen complications and patient frustrations. Future investigators need to provide fast Internet connectivity and up-to-date hardware, including large screens, nonintrusively in the home environment. Because of the technical difficulties with the DocBox technology, a full trial is not planned at this time.

Shortness of breath and distress related to dyspnea significantly improved after the 6-min walk, while body strength and 6-min walk distance did not improve. QOL measures improved in both intervention and control groups. This population tends to be isolated and often homebound, and any social interaction may improve QOL. Social desirability may have also positively affected outcomes. Although not significant, the strong effect size of the General Sleep Disturbance Scale indicates possible improvement in insomnia for patients in the TeleYoga group, suggesting that sleep quality should be included in future studies of yoga in this population.

Recruitment in this dual diagnosis population is challenging because many patients are cared for in primary care clinics and never reach a specialty practice, and although they actually have both conditions, they may only have one official diagnosis.³¹ Many patients and providers under-recognize the challenges of a dual diagnosis. Because they are often homebound, the authors found it was difficult to find patients with both of these diagnoses and communicate with them. The overall frailty of the population may also contribute to recruitment challenges. Although participants were fully engaged with the study, some were limited in their ability to participate because of frailty, and others did not qualify for the study because of frequent exacerbations and poor health. Often these patients are seen by multiple providers from various disciplines and coordination of care and consent for participation can be another challenge to recruitment and enrollment.

The authors' findings have implications for future research in COPD-HF populations and using home-based interventions. Conducting assessments at home was important in this frail population and minimized missing data. Patients who are unable to attend an in-person intervention are unlikely to be able to attend baseline and follow-up outcomes testing sessions. Future research in this fragile and often homebound population should use assessment tools validated for home use. The home protocol for the 6-min walk test cannot be compared with 6-min walk results done using the American Thoracic Society guidelines,³² but it has been validated for home use and provides valid within-subject comparisons.²² Although the space needed for this 6-min walk was only 20 feet, the authors found that space was sometimes difficult to access in a given subject's home. Clutter issues, small living environments, and short hallways in public apartment buildings required creativity on the part of the outcomes testing personnel. It was therefore important to document clearly the logistics of the baseline test so that the same conditions could be replicated during follow-up testing for valid comparisons. In conducting home-based research, it is also important to carefully assess resources and evaluate the availability of all required equipment for both outcomes testing and implementation of the intervention. For example, the authors assumed that patients would have access to basic resources such as extra pillows and blankets to use as bolsters, and chairs, wall, and floor space for yoga practice. This was not always the case and sometimes interfered with the quality of the yoga intervention.

The Health Education control group intervention provided ongoing interaction and attention from the intervention nurse and was well accepted by the control group participants.²⁰ The weekly educational materials in the mail and follow-up telephone calls provided value to participants with no impact on well-being.²⁰ This control intervention can be recommended for other studies of nonpharmacologic interventions in this population.

Limitations

The authors acknowledge that there are limitations to this pilot study. The small sample size of homogenous subjects limits generalizability of their findings. The use of convenience sampling means that there is a risk of selection bias, and the characteristics of the four participants who declined enrollment in the study could not be compared with the study participants. Reports of vital signs before and after TeleYoga sessions were not observed, and there is a possibility that they were fabricated to please investigators, although this is thought highly unlikely. The time allotment (“dose”) of the intervention and control intervention was not equal, so although the control was acceptable, the authors recommend that in a full trial the attention provided to participants is balanced between the two groups. The feasibility measures did not include cost estimates, and cost should be considered in future research in this area. Future studies could compare several doses of a yoga intervention to traditional cardiopulmonary rehabilitation in patients with the dual diagnosis of COPD and HF, as these data are not yet available.⁷

Conclusion

Despite their frailty, patients diagnosed with both COPD and HF were able to safely perform yoga in the home setting. Both diagnoses have poor prognoses; however, regardless of how frail or robust they appear, this intervention was well received and had high patient satisfaction. Yoga can be considered a palliative care intervention, as it can be modified for all levels of functional status, and has the potential to improve symptom status. In patients who may have heard that there is “nothing more” that can be done, a complementary therapy such as yoga can provide additional support with minimal safety concerns, even in patients who are receiving maximal therapy for both conditions.

Footnotes

Acknowledgments

The authors appreciate the work of yoga teacher Lisa Tidman, B.S., and DocBox personnel Lawrence Keyes and Bob D'Orazio for their technical support of this project. Trial registration number: NCT-02078739.

Author Disclosure Statement

No competing financial interests exist.

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