Exercise Combats Frailty: Physical Exercises as a therapy to combat Frailty

Population ageing is one of the most discussed global phenomena in the present century. Countries with a large population like India have a large number of people now aged 60 years or more. The population over the age of 60 years has tripled in last 50 years in India and will relentlessly increase in the near future. According to census 2001, older people were 7.7% of the total population, which increased to 8.14% in census 2011. The projections for population over 60 years in next four censuses are: 133.32 million (2021), 178.59 (2031), 236.01 million (2041) and 300.96 million (2051).

Frailty is a state of vulnerability that carries an increased risk for adverse outcomes. It can be viewed as a transition phase in older people between good health and poor health. Frail older adults are less capable of tolerating the stress of medical illness, hospitalization, and immobility. Common signs and symptoms are fatigue, weight loss, muscle weakness, and progressive decline in function. Frailty is more prevalent in older people and in those with multiple medical conditions. Frail in Elderly is usually manifested as weakness, impaired mobility, balance and minimal reserve. It is seen in the older population as unintentional weight loss, fatigue, exercise intolerance, weakness, slowed motor performance and low physical activity.

Concomitant with age, there is decline in voluntary physical activity which is associated with decrease in numerous measures of exercise capacity including peak oxygen consumption (VO₂pea), muscle strength, and fatigability which ultimately leads to frailty. Recently it has been recognized that older adults who are obese also meet criteria for frailty because of decrease muscle mass and strength that occurs with aging (sarcopenia) and a need to carry greater body mass due to obesity. This is associated with an increased risk of fall, ADL disability, hospitalization and death and at times with Chronic Health diseases like Osteoarthritis, Diabetes Mellitus, Hyper Tension, angina, Congestive Cardiac Failure, pulmonary disease or Cancer.

Frailty due to alteration in multiple physiological systems (including inflammatory, skeletal muscle, endocrine, clotting, and haematological) and dysregulation of mechanisms between these systems to maintain homeostasis

With increasing age, there is a well-described decline in voluntary physical activity which is associated with decreases in several measures of exercise tolerance including maximal aerobic capacity, muscle strength, and fatigueability, leading to an increase risk of frailty.

Frailty increases the risk for loss of functional independence and decrease in quality of life, the identification of cost-effective interventions to prevent or ameliorate frailty is one of the most important public health challenges.

In recent years, increased physical activity or regular exercise training has been proposed as preventive strategies for frailty and its adverse outcomes, as it can target four of the frailty criteria: weakness, low physical activity, slowed motor performance, and exercise intolerance. Epidemiological studies suggest that regular physical activity is associated with a decreased risk of ADL disability in older adults, which is an adverse outcome of frailty.

Frailty is not a contra-indication to physical activity, rather it maybe one of the most important indications to prescribe physical exercise. Longitudinal studies have demonstrated that regular physical activity extends longevity and reduces the risk of physical disability. In fact, cardio-respiratory fitness has been found to be a significant mortality predictor in older adults, independent of overall or abdominal obesity

Benefits of Exercises:

With age, there is a decline in the muscle mass and strength and it is even more distinct in frailty. Studies show that exercise is favourable in older adults, even in the frailest subset benefit from it. The benefits of exercise in the elderly are numerous and include increased mobility, improved performance of activities of daily living (ADL), better gait, less incidence of falls, increased bone mineral density, and improvements in overall wellbeing.

Aerobic/endurance exercise training

Aerobic capacity often measured as VO₂peak declines with age and contributes to a decrease in the older adult’s ability to perform activities of daily living. This is largely due to three major causes:

1) A decline in the ability of the cardiopulmonary system to deliver O₂

2) A decline in the ability of the working muscle to extract O₂, and

3) A decline in metabolic muscle mass and parallel increase in metabolically inactive fat mass.

Indeed, probably one of the most notable effects of endurance training is on VO₂peak which is an important determinant of frailty in older adults. The improvement in VO₂peak with endurance exercise training would be thought to reduce frailty in older adults and thus counter the decline in VO₂peak with aging and physical inactivity. There are two mechanisms by which aerobic exercise is thought to alter the frailty phenotype: improvement in the maximal oxygen uptake (VO₂ peak) and increased muscle mass. VO₂ peak is defined as the maximum rate of oxygen consumption measured during vigorous exercise and is closely related to sub-maximal endurance exercise capacity and exercise tolerance. Another important adaptation to endurance exercise training is an increase in muscle oxidative capacity, which results in fatigue resistance or increased muscle endurance.

Progressive Resistance exercise training

There is well-documented evidence that muscle strength and mass decreases with advancing age.

Muscle strength decreases approximately 12% to 15% per decade after the age of 50 years in both males and females going up to a 30% decrease by 70 years age. Most of the decline in strength can be explained by selective atrophy of type II muscle fibres and the loss of neuronal activation.

Despite these age-related effects on muscle, resistance exercise training still has been found to increase strength in older adults. Motor performance in older adults has also been shown to improve after resistance training. Several studies have shown that resistance exercise training increases muscle mass and thus muscle strength in both younger and older adults. However, the response to resistance training appears to be attenuated in older adults with mobility limitations or other co-morbidities. In healthy older adults, four months of progressive resistance training increased muscle mass by 16 to 23%, whereas it increased muscle mass by 2.0–9% in frail older adults

Combined aerobic and resistance exercise

Given the beneficial results seen with aerobic or resistance exercise alone and that both types of exercise target specific distinct features of frailty, there has been recent interest in whether an intervention with both components is beneficial for frail older adults. Therefore, the few exercise interventions conducted in frail older populations have mostly used combined aerobic and resistance exercise and found to have a much promising effect than isolated aerobic or resistance training alone.

Effect of exercise interventions on the adverse outcomes of frailty

Several studies have examined the effect of exercise on falls, a common adverse outcome of frailty. After a single fall, the risk of skilled nursing facility placement in older adults increases three-fold, after adjustment for cognitive, psychological, social, functional and medical factors. In addition to falls, ADL disability is of major concern in frail individuals as it is associated with higher rates of mortality. Combined resistance exercise training with balance training and home safety and assistive device evaluations, rates of ADL disability decreased only in those with moderate frailty, but not in those with not in those with severe frailty. Moderate frailty was defined as either the inability to perform a rapid gait test (requiring more than 10 seconds to walk a 3 meter course) or stand up from a chair with arms folded, and severe frailty was defined as having both characteristics

Adverse outcomes of exercise

Most exercise intervention trials studied the effects on features of frailty and the adverse outcomes of frailty.  Physical exercise can reverse frailty (frail reverse to non-frail) or if older adults can convert from a greater state of frailty to a lesser state of frailty with exercise suggesting that it is possible to successfully “treat” frailty.

Molecular and cellular mechanisms underlying exercise training

Aging and physical inactivity are associated with increased levels of chronic inflammation. Inflammatory cytokines have direct catabolic effects on skeletal muscle. These cytokines also induce insulin resistance, which contributes to sarcopenia and frailty by reducing muscle protein synthesis. Accordingly, an important mechanism by which exercise training reduces frailty is by suppressing muscle inflammation and promoting anabolism which leads to an increase in muscle protein synthesis

Future Directions

Exercise and physical activity are promising interventions for frailty, and several studies are currently underway to examine their impact. Adherence to an exercise regimen is key to its beneficial effects, and strategies to overcome this barrier need to be developed before exercise as treatment modality is implemented on a wide scale.

Although exercise uniformly had a positive impact on functional measurements, exercise seemed to be more beneficial in frail people living in long-term care facilities compared to the community (probably due to floor and ceiling effects of some outcome measurements) and in the earlier stages of frailty compared to the later stages of frailty (probably due to less ability to exercise with greater degree of frailty). With respect to specific type of exercise program, a multi-component training was found to have a more positive effect on the functional ability and adverse health consequences of the frail people. Interventions lasting longer than five months seemed to result in greater benefits on the adverse health consequences of the frail people. The duration for each session of exercise that was most beneficial was 30–60 minutes, which is less than what is usually recommended for healthier older adults. In addition, cognition is a factor that should be considered. A significant proportion of older adults are cognitively impaired, which may impact their ability to properly adhere to a regular exercise regimen. However, if caregivers are involved, this may not be such a barrier.

Based on currently available evidence, a multi-component exercise program that includes aerobic activity, strength exercises, and flexibility is recommended in frail older adults

Recommendations:

In older adults of the 60 years and above age group, physical activity includes leisure time physical activity, transportation (e.g. walking or cycling), occupational (if the individual is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities.

The recommendations in order to improve cardio-respiratory and muscular fitness, bone and functional health, reduce the risk of NCDs, depression and cognitive decline are:

1. Older adults should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, older adults should increase their moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate-and vigorous-intensity activity.

4. Older adults, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week.

5. Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week.

6. When older adults cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow.

Inactive people should start with small amounts of physical activity and gradually increase duration, frequency and intensity over time. Inactive adults and those with disease limitations will have added health benefits when they become more active.

Exercise Recommendations for frail older adults:

Aerobic exercise: Moderate to vigorous activity enough to raise the pulse rate to 70–80% of the maximum heart rate. Activity performed for a minimum of 20–30 minutes at least three days per week

Resistance exercise: The progressive resistance program should involve all major muscle groups of the upper and lower extremities and trunk. One set of 8 to 10 different exercise, with 10 to 15 repetitions per set, performed 2–3 non-consecutive days per week. Moderate-high intensity training is recommended, in which moderate intensity is 5 or 6 on a 0 to 10 scale.

Flexibility and balance exercise: Stretching to the point of tightness and holding the position for a few seconds. Flexibility activities are performed on all days that aerobic or muscle strengthening activity is performed. Balance training exercise 2–3 times per week.

Modified Wall Suryanamaskar: Hypothesised to be a good exercise for improving balance and reaction time in the community dwelling elderlies. Also can be a good combination of aerobic and resistance training for improving strength, endurance, flexibility and aerobic capacity in this population.

Virtual Reality Training: Virtual reality game exercise have been found to improve balance and gait of elderly individuals in community dwelling elderlies.

Conclusion: An exercise “prescription”

Majority of studies suggest that clinicians should recommend regular physical activity or exercise training to frail older adults. All adults over 60 years should participate in 150 minutes (2 hours and 30 minutes) of moderate aerobic exercise per week. Although most trials studied resistance exercise training, we would encourage frail older adults to start with an aerobic activity such as walking, as it is more accessible. If possible, resistance exercise training should be added. Depending on the degree of frailty, supervision may or may not be required. For individuals with severe frailty, evaluation by a rehabilitation profession is recommended.

The majority of evidence shows that regular physical activity or exercise is beneficial for older adults who are frail or at high risk of frailty. Studies have shown the number adverse events are minimal, and the gains of regular exercise clearly outweigh the risks.

References:

1.   Liu CK, Fielding RA. Exercise as an intervention for frailty. Clin Geriatr Med. 2011 Feb;27(1):101-10. doi: 10.1016/j.cger.2010.08.001. Review. PubMed PMID:21093726; PubMed Central PMCID: PMC3005303.

2.   Aguirre LE, Villareal DT. Physical Exercise as Therapy for Frailty. Nestle Nutr Inst Workshop Ser. 2015 November; 83: 83–92. doi:10.1159/000382065.

3.   Ministry of health and family welfare. New Delhi: Director General of Health Services, MOHFW, Government of India; 2011. National Program for Health Care of the Elderly (NPHCE): Operational Guidelines 2011.

4.   Central Statistics Office. New Delhi: Central Statistics Office Ministry of Statistics and Programme Implementation, Government of India; 2011. Situation Analysis of the Elderly in India.

5.   Verma R, Khanna P. National Program of Health-Care for the Elderly in India: A Hope for Healthy Ageing. International Journal of Preventive Medicine, 2013;4(10): 1103–1107.

6.   Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts 

outcomes in middle aged African Americans. J Nutr Health Aging. 2012 Jul;16(7):601-8. 

PubMed PMID: 22836700; PubMed Central PMCID: PMC4515112.

7.   Shaheen M, Puri S, Tandon S. An Overview of Frailty in Elderly. Journal of The Indian Academy of Geriatrics, 2016; 12:58-65

8.   World Health Organization (WHO). Global Recommendations on Physical Activity for Health. Viewed on http://www.who.int/dietphysicalactivity/pa/en/ [Viewed on 2017 March 30]

9.   Park EC, Kim SG, Lee CW. The effects of virtual reality game exercise on balance and gait of the elderly. J. Phys. Ther. Sci. 27: 1157–1159, 2015

10.              Shaikh A, Shimpi A, Rairikar S. Effectiveness of Modified Wall Suryanamaskar Training for enhancement of Balance and Reaction time in community dwelling elderlies. (AoP)

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