Role of Hasya Yog (Laughter Therapy) Clubs in Promotion of Health in Community

Summary:

Health promotion covers all aspects of those activities that seek to improve the health status of individuals and communities. Many studies have proved that laughter has both, short term and long term benefits on our physical, mental and emotional health. Our purpose was to assess role of Hasya Yog' in promotion of health in the community. 400 people, of which 200 participated in Hasya Yog, were assessed on the basis of three parameters; respiratory function assessed by peak expiratory pressure and maximal inspiratory pressure, flexibility measured by using a sit and reach test and quality of life was assessed by SF 36 questionnaire. Results were obtained using 'unpaired t test' and ‘Mann Whitney Test’ for comparing the parameters. A significant difference was found while comparing respiratory function using PEFR and PI max (p<0.001). Flexibility test was also statistically significant (p < 0.01). In case of quality of life physical health component was better in Hasya Yog members group whereas, mental health component was not found to be statistically significant. (p=0.24). Thus, Hasya Yog (Laughter clubs) definitely plays a major role in promotion of health in the community, with respect to Respiratory function, flexibility and quality of life (physical component). However, we found its limited role in influencing the mental component of quality of life.

Hasya Yog:

21^st of June 2015 is being celebrated as International Yog Day. The World health organization (WHO) defines health as a state of complete physical, mental and social wellbeing, and not merely an absence of disease or infirmity. Health promotion is a part of primordial and primary approaches of health care delivery system. It is the process of empowering people to make healthy lifestyle choices and improve the quality of life. An article ‘Health Promotion by Social Cognitive Means’ by Albert Bandura, examines health promotion and disease prevention from the perspective of social cognitive theory. Active community participation is crucial for any health promotion process to be successful.

India is considered as the birth place of the Yog concept which has now got a global recognition. Yog does not only help in developing the physical functioning and health, but has also been proved to be extremely efficient in improvising the mental and cognitive functions across all ages. In India, increase in self-help clubs and voluntary organizations have also developed to encourage this. Janet Patford and Helen Breen suggested that clubs attract older people by offering diverse activities. Hasya Yog Mandal or “Laughter club” is one such social activity started more than 13 years back. World Laughter Day was celebrated recently on 3^rd May. Joel Goodman said, “Seven days without laughter makes one weak” and yes, laughing matters. An observational research done by Colin Greaves proved that in 12 months, there were significant improvements in depression and social support and marginally significant improvement in Short Form 12 physical component in geriatric participants engaging in programs of creative exercise and/or cultural activities with an emphasis on social interaction. Tan SA, Tan LG et al proved that humour appears to attenuate catecholamines and myocardial infarction (MI) recurrence and thus may be an effective adjunct in post cardiac arrest care. Laughter has physiological, psychological, social and spiritual benefits and also benefits in enhancing the quality of life with hardly any adverse effects. Also practically there are no contraindications of laughter. Therapeutic efficacy of laughter is mainly derived from spontaneous laughter (triggered by external stimuli or positive emotions) and self-induced laughter (triggered by oneself at will). However, the medical literature contains little on humour, and very little research has been conducted on this common aspect of human communication. Although individual reviews and opinions are published regarding therapeutic use of laughter an organized study on laughter is not reported. Our study assessed the effect of these Hasya Yog mandals in promotion of health of the subjects by indirectly assessing physical fitness components and quality of life in the community dwelling elderly individuals.

We performed a cross sectional survey in 2009-2010 in Pune city on 400 elderly people of whom 200 subjects were regularly attending the laughter club activities with at least 80% attendance while other 200 did not participate in any other physical fitness activities except leisure walking and were selected from the similar population as the Hasya Yog mandal members. Informed consent was taken from all the subjects for their willingness to participate in the survey which was approved by the local ethical committee. Outcome measures that were used for assessing quality of life was the Short form 36 scale (SF36), for assessing flexibility, the modified sit and reach test, for assessing respiratory function the Peak Expiratory Flow Rate (PEFR) by Mini Wright’s peak flow meter and maximum inspiratory pressure (PI max) by pressure gauge instrument. These measurements were taken in a comfortably sitting position for each subject and best of three readings was taken. Sit and reach test was carried out for each subject after a prior warm up and mild stretching. Test was done using a ruler and a marker as per feasibility. Any subject showing symptoms of back pain while performing this test was excluded from the study. Quality of Life (QoL) was measured by the SF-36 scale. The procedure of filling the scale was explained and doubts, if any, were solved. However, this definitely depended on the intelligence and understanding of the subjects which was not under our control. Completed forms were collected from the members. Comparison between two groups on the basis of respiratory function, flexibility and quality of life was done using 'unpaired t test' for comparing respiratory function and flexibility parameters and ‘Mann Whitney Test’ for QoL with alpha set at p<0.05.

Table 1: Demographic Data:

Variable	Laughter club group	Non Laughter group
Samples	200 (Males 59, Females 121) Excluded 20	200 (Males 52, Females 108) Excluded 40
Age (in yrs)	62.88 ± 8.24 (Mean ± SD) (n=180)	60.66 ± 7.84 (Mean ± SD) (n=160)

EXCLUDED DATA SUBJECTS	Number
Smokers	08
Structural Back Problems (Prolapsed Intervertebral Disc, Lysthesis etc.)	09
Obstructive / Restrictive Lung Pathology	06
Taking Antidepressants / Anxiolytics	05
Additionally Participating in Yoga / Health Clubs	14
Incomplete filled Forms	05
Inability To Perform Tests	13
TOTAL	60

Table 2: Comparison between both the groups on the basis of respiratory function, flexibility and quality of life.

Variable	Laughter club group (mean ± SD)	Non Laughter group (Mean ± SD)	p Value
PEFR (Lt/ min)	278.58 ± 75.5	239 ± 78	< 0.05
Pi Max (cms H2O)	75.21 ± 44.58	57.3 ± 32.9	< 0.05
Flexibility (cms)	30.4 ± 9.375	27.74 ± 9.733	= 0.01
Physical Function	87.5 ± 13.8	79.84 ± 19.95	< 0.05
Role Physical	83.34 ± 19.37	79.76 ± 21.8	< 0.05
Bodily Pain	79.08 ± 19.91	66.24 ± 24.54	< 0.05
General Health Perceptions	75.77 ± 18.09	68.03 ± 27.85	< 0.05
Role Emotional	84.82 ± 21.6498	78.2 ± 21.75	= 0.24
Vitality	81.61 ± 19.58	68.75 ± 25.25	= 0.24
Mental Health	83.06 ± 15.6	77.15 ± 22.53	= 0.24
Social Function	96.1 ± 10.25	95.51 ± 9.0361	= 0.24
Physical Component Summary	81.43 ± 11.79	73.46 ± 14.85	< 0.05
Mental Component Summary	86.4274 ± 11.4413	79.903 ± 12.50	= 0.24

The values obtained and analysed showed a significant difference (p<0.001) between peak expiratory flow rate, maximal inspiratory pressure, flexibility by sit-and-reach test, physical QoL and physical QoL components between both the group. Difference between scores of mental QoL and mental QoL components scale were not found to be significant (p>0.001).

How Does Laughter (Hasya Yog) Help Us?

Impact of laughter on general well-being of patients is been described, however an organized controlled study in laughter clubs is not been done. The function of respiratory system depends on many factors out of which important ones are the central nervous system with the neural pathways and the muscles of respiration and chest wall. The lungs are not capable of inflating themselves. The force for this inflation must be supplied by the muscles of respiration. Respiratory function was taken as a surrogate measure for physical functions. It was judged by two parameters: PEFR and PI max. These are the indicators of expiratory and inspiratory function respectively. Hasya Yog members demonstrated a significant difference in both. Hence, their respiratory function was better than the non-participants in laughter group. However, low PEFR and PI max scores might also be due to the subclinical conditions which were not assessed by us. The above obtained result is supported by research findings which proved that respiratory system is coordinated in a rather precise way with laryngeal activity during a laugh. Phasic respiratory efforts are present during laughter. Laughter involves deep inspiration followed by forceful exhalation. Due to increased respiratory muscle strength by regular laughter therapy, indirectly we must have got good scores of PEFR and PI max. Flexibility training is an integral part of the laughter club protocol wherein stretching exercises are been given to all the members of laughing for initial 10 minutes.

Muscles shorten and lose elasticity, due to increased cross linking between collagen tissues that occurs with normal aging process. In our study flexibility of hamstrings and back was assessed by sit and reach test and was found to be good in Hasya Yog members. This improved flexibility may in turn reduce the chances of having any further musculoskeletal ailments, pains, gait limitation and risks of falling. This was reflected in our study by better physical quality of life score in this group. Cunha et al too found that stretching exercises were effective in reducing pain and improving range of motion and quality of life in female patients with chronic neck pain. Stretching adds to functional fitness, helping to stay agile and independent as long as possible, improving general health. Static stretching is preferred to create long lasting lengthening of muscles and surrounding tissue. It is a safe and well tolerated form of stretching. This might be the reason why static stretching techniques practiced in laughter clubs were beneficial.

Physical activity improves patients’ ability to perform tasks and patient’s perception of impact of disability on their physical functioning. There was significant difference in the physical component summery (PCS) scores between Hasya Yog group and other group. PCS includes four components physical functioning (PF), role limitation due to physical health problems (RP), bodily pain (BP) and general health perception (GP). Hasya Yog group showed higher mean scores for all and reported less limitation in doing activities of daily living (ADLs) like carrying household stuff, stair climbing, walking etc. All exercises of laughter club help in performing activities more efficiently. Whereas; people in non-laughter group and having sedentary life style leads to reduction in their physical abilities due to disuse. In the laughter group, we got significantly low score for pain. This is supported by the research which showed that laughter and distraction both increased the pain tolerance by causing release of endorphins which are natural pain suppressors. Their general health perception reported was also good. This is supported by research article published in American medical association’s journal, which conclude that “A humour therapy program can increase the quality of life for patients with chronic problems and that laughter has an immediate symptom-relieving effect for these patients, an effect that is potentiated when laughter is induced regularly over a period.” Series of researches did by Dr. Lee Berk and colleague put forth the fact that laughter therapy increases level of activated T cell, antibodies IgA, gamma interferon, IgB which ultimately increases the immunity. A lot of interaction between peers facing similar problems might help them to cope with the diseases better and increase the self-confidence. This might be reflected in the results as, experimental group showed positive perception about their health.

Mean score for quality of life (mental component) in the laughter group was higher as compared to the other group. However, statistical comparision did not show a significant difference as p = 0.24. Mental component summary is calculated using four components of SF-36 scale; role limitation due to emotional health problems (RE), mental health (MH), vitality (VT) and social functioning (SF). Laughter club members showed higher scores on first three parameters. Scores for social functioning was found to be similar for both the groups. It is also subjective and equally dependent upon the interpretations and perceptions of the individual. This could be the reason why laughter club activities might not be having a significant role in influencing mental health of an individual. Research indicates that interventions, which promote active social contact, which encourage creativity, and which use mentoring, are more likely to positively affect health and well-being. Clubs provide a forum where people can meet, talk, and receive social acknowledgement on a regular basis. They thus help to foster a sense of connectedness and may reduce the loneliness that older people often experience as a result of retirement, bereavement, and children moving away. Laughter works as a safety valve that diffuses tension, reduces stress related hormones like epinephrine, cortisol etc. and aids in relaxation. In our study, the Hasya Yog group showed a positive response to questions about feeling calm and peaceful which is also supported by a recent study indicating that laughter resulted in H-reflex suppression. Both laughter and simulated laughter decreased spinal motor excitability causing muscle relaxation and reducing stress. People who are engaged in any of the social activities get an opportunity to share their emotions, might feel the intensity of such problems less as compared to others who are socially isolated. Thus, summing all the researches and results observed in our study, we can conclude that participation in a regular exercise program and engaging in social activities as in laughter clubs is an effective intervention.

Thus, we concluded that Hasya Yog (Laughter therapy) definitely play a major role in promotion of health in community with respect to respiratory function, flexibility and quality of life (physical component). However, its role was found to be limited in influencing the mental component of quality of life.

We would like to thank all the participants who participated in the study with co-operation and enthusiasm.

Dr. Nishigandha R Supekar (PT)

Dr. Apurv P Shimpi (PT)

Dr. Alopa V Madane (PT)

The above study has been published in the Indian Journal of Physiotherapy & Occupational Therapy, April-June 2014, Vol. 8, Issue. 2; Page 110-114

The Hypertrophied Patella – Does it really exist?

The Knee joint reveals its mysteries far more often than expected. So often a simple case of fracture patella with a Tension Band Wiring (TBW) turns out to be a nightmare for the Physiotherapy management.

The fracture of the patella is one of the commonest conditions that a Physiotherapist encounters during the clinical practice. The patella (knee cap) is a sesamoid bone, i.e. it is a bone in between the tendon of the quadriceps muscle and is a cancellous (porous) type of a bone. Although the patella is within the tendon of the quadriceps, it does not separate the quadriceps tendon, but infact it is embedded within the extensor retinaculum of the quadriceps. The patella acts as a pulley to increase the moment arm of the knee joint and increases the efficacy of the quadriceps muscle to bring about extension of the knee joint. This is such a beautiful bio-mechanical mechanism which is really unique in the human body.

The quadriceps group of muscles are made of 4 different muscles, viz the single joint (uni-articular) 3 Vastii (Vastus Lateralis, Vastus Intermidius and Vastus Medialis) which are phasic, red muscles responsible for the knee joint anterior compartment dynamic stability and the two joint (bi-articular) Rectus Femoris which is flexor of the hip and extensor of the knee joint and is a tonic, white muscle responsible for force production and torque generation of the knee joint during extension in open and closed chain activities.

The patella works as a pulley glided by the shape of the articular surface of the femoral condyles. It has the capability to move medial to lateral, superior to inferior and rotate inwards and outwards within the articular capsule of the knee complex. This variation in movement allows the patella to move and align itself in relation to the different fibres of the vastii and rectus to bring about an efficient extension of the knee. It is generally assumed that during extension of the knee from 120 – 0 degrees, the patella aligns the fibres of the vastus lateralis fibres in 120 – 80, vastus intermidius aligned during 80-40 and vastus medialis aligned during 40 – 0 degrees of the extension. Thus the patella plays an extremely crucial role in knee extension, not by merely increasing the knee joint moment arm, but also by aligning the fibers of the quadriceps. The rectus femoris is responsible for force generation for the knee movements and is extremely crucial for activities like walking, running, kicking (a ball) etc.

Flexion of the knee is brought about by the bi-articular (2 joint) hamstrings group of muscles which constitutes of the semi-tendinosis, semi-membranosis and the biceps femoris. During flexion of the knee from 0-120 degrees, the patella undergoes a tracking movement in the inferior (downward) direction. It carefully moves within the space of the femoral condyles within its lower articular surface after around 90 degrees of knee flexion and thus reduces the tension generation in the capsule of the knee joint.

This mechanism and function of the knee is severely hampered when the patella is fractured. Although the patella is not a weight bearing bone during normal bipedal ambulation, its fracture completely disrupts the extensor mechanism of the knee making this entire system collapse. Newer line of orthopaedic surgical management offers wonders in management of the patellar fractures. The tension band wiring fixation with ‘Krichners’ wire fixation seems to be the most commonest and most reasonable line of management for patellar fractures wherein the distraction pull by the quadriceps (and the ligamentum patellae in the other direction) is converted into compression forces by the TBW thereby accelerating the early healing the restoration of the function of the extensor mechanism.

But the patella, which is a porous bone, bleeds during the course of the trauma leading to its fracture. This bleed gets confined along with patellar fracture within the extensor retinaculum and as the patella gets healed and calcified, can also get calcified. Although this is not very evident in the radiograph (X-Ray), it can still be visualised on careful observation, mainly after 4-6 weeks post fracture. But it is best evident to the clinician by palpating the patella which seems to be big and enlarged (comparison with the opposite knee is extremely useful for confirmation). This enlarged size of the patella is poorly studied in literature and thus have been coined as a “Hypertrophied Patella” by me. Although the term hypertrophy is associated and used with muscles in relation with an increase in their size and cross sectional area, it seemed appropriate to use this term for the patella in this condition also (although not an absolutely scientific term). The term “Hypertrophy of the Patella” has been used in literature by Cave (1950) and Linthoudt (2008), it has been in relation to the multiple epiphyseal dysplasia, not the adult patella per se.

The patella, which seems to be enlarged on palpation, does not function appropriately in regards to its flexion function of the knee. It is extremely difficult for the patella to move within the femoral condyles after 90 degrees of knee flexion and thus starts becoming a nightmare for the Physio to obtain a full range of the knee. Clinically, this state of the knee may not affect the extensor mechanism of the knee joint and thus, the bio-mechanical functions of the quadriceps tend to remain intact. But in few of the cases, a dysfunction in the extension mechanism has been found, primarily due to the reduced mobility of the patella. The swelling around the patella is not easily and readily manageable and as it tends to consolidate, it reduces the mobility of the patella in all the directions. This prevents the patella from being aligned to the respective fibers of the quadriceps and leads to loss of efficiency of the knee extensors. It can also lead to compression of the patella against the articular surfaces of the femur (specially the medial condyle of the femur) leading to early degeneration of the articular cartilage of the patella as a complication in the near future. Thus controlling the swelling (oedema) and restoring a normal patellar mobility becomes a priority in the early management of patellar fracture rehabilitation.

The goal for Physiotherapy management in a case of fracture patella includes:

1. Pain management

2. Controlling the swelling

3. Increasing the range of motion of the knee joint

4. Increasing the strength of the extensor mechanism

5. Increasing the strength of knee flexors

6. Early weight bearing and ambulation

7. Functional restoration

1. Pain management:

This can be obtained by Cryotherapy (or heat if swelling is not an issue), and by low velocity oscillations for knee and patella

2. Controlling the swelling:

Cryotherapy, compressions, knee brace (if required)

3. Increasing the range of motion of the knee joint:

This is the most crucial challenge. The patient cribs and curses every morning due to their inability to squat. Patellar mobilisation and quadriceps MFR helps in gaining early knee range till 90 degrees. But range beyond this is very difficult to obtain and may take as long as 6 months to be achieved. Being too impulsive and over-enthusiastic in this situation may prove to be too dangerous as repeated application of force and pressure (passively or by CPM machine etc) may cause over lengthening of the ligamentum patellae due to collagen distraction and may produce loss of efficiency of the extensor mechanism. The therapist may perceive a progressive weakness in the quadriceps strength in 4-6 weeks, not realising that the overstretching has led to dysfunction of knee extensors and loss of efficiency of force production at the tibia. This, unfortunately, cannot be reversed by any amount of strengthening of the quadriceps and thus has to be prevented at all costs.

4. Increasing the strength of the extensor mechanism and Knee flexors:

Open chain exercises till 4 weeks and later combination of open and closed kinematic chain exercises is very useful for gaining the strength of the knee muscles. Care should be taken to improve on the Endurance of the Vastii (by RPE) and the strength of the Rectus femoris and Hamstrings (by 1 RM and PRE), as per their functional needs. Also to understand the various angles that the vastii function and thus multiple angle, short arc training can be more beneficial rather than full range movements.

5. Early weight bearing and ambulation:

There is no contraindication for early weight bearing and gait training in these cases. Always, a good rapport and communication with the operating Orthopaedic Surgeon turns out to be a blessing. Full weight bearing, as early as in 4 weeks, can be obtained. Gait training is extremely crucial as the reduced patellar function affects the loading response, mid stance, pre swing and swing phases of Gait and can result in a Stiff Knee gait pattern. Pain is rarely a hindrance in Gait training.

6. Functional restoration:

Activities such as sitting on low surfaces, squatting, cross leg sitting etc, requiring more than 90 degrees of knee flexion may be very difficult to obtain for almost 4-6 months. But walking, stairs, riding etc is not much of a hassle. Always maintain good communication with the patient and surgeon and have clarity of thoughts in regards to the Physiotherapeutic management.

Thus, the patellar fracture turns out to be a simple, but challenging aspect in PT rehab. The knee gains a good range and function in the near future due to reabsorption of the excess calcification with a progressive aligned and directed force of the quadriceps and is not a matter of worry at all. (Although is a time consuming process). Although not much documented, the “Hypertrophied Patella” does seem to exist and also requires a better understanding of the knee joint and is a challenge worth accepting.

Dr. Apurv Shimpi (Community Physiotherapist)

1. Cave EF, Rowe CR. The Patella, Its Importance in Derangement of the Knee. J Bone Joint Surg Am, 1950 Jul; 32 (3): 542 -566 

2. Van Linthoudt D. Patellar hypertrophy: rare abnormality associated with a multiple epiphyseal dysplasia. Praxis (Bern 1994). 2008 Aug 13;97(16):893-7. French.

3. Gosal HS, Singh P, Field RE. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester — a study of 37 cases. Injury, Int. J. Care Injured 32 (2001) 129–135

4. Hoshino MC,  Tran W, Tiberi JV, Black MH, Li BH,  Gold SM,  Navarro RA. Complications Following Tension-Band Fixation of Patellar Fractures with Cannulated Screws Compared with Kirschner Wires. J Bone Joint Surg Am April 2013; :653-659.

5. Baran O, Metin Manisali M, Berivan Cecen B. Anatomical and biomechanical evaluation of the tension band technique in patellar fractures. International Orthopaedics. August 2009, 33(4): 1113-1117

6. Cramer KE, Moed BR. Patellar Fractures: Contemporary Approach to Treatment. J Am Acad Orthop Surg November 1997; 5:323-331.