Effect of relaxation-breathing training on anxiety and asthma signs/symptoms of children with moderate-to-severe asthma: A randomized controlled trial

Abstract

Background

Emotional stress triggers and exacerbates asthma in children. Reducing anxiety in adults by relaxation-breathing techniques has been shown in clinical trials to produce good asthma outcomes. However, more evidence is needed on using this intervention with asthmatic children.

Objective

To evaluate the effectiveness of combined self-management and relaxation-breathing training for children with moderate-to-severe asthma compared to self-management-only training.

Design

Two-group experimental design.

Setting and participants

Pediatric outpatient clinic of a medical center in central Taiwan. Participants were 48 children, ages 6–14 years, with moderate-to-severe asthma and their parents.

Methods

Participants were randomly assigned to an experimental or comparison group and matched by gender, age, and asthma severity. Both groups participated in an asthma self-management program. Children in the experimental group were also given 30 min of training in a relaxation-breathing technique and a CD for home practice. Data on anxiety levels, self-perceived health status, asthma signs/symptoms, peak expiratory flow rate, and medication use were collected at baseline and at the end of the 12-week intervention. Effects of group, time, and group–time interaction were analyzed using the Mixed Model in SPSS (12.0).

Results

Anxiety (especially state anxiety) was significantly lower for children in the experimental group than in the comparison group. Differences in the other four physiological variables were also noted between pre- and post-intervention, but these changes did not differ significantly between groups.

Conclusions

A combination of self-management and relaxation-breathing training can reduce anxiety, thus improving asthmatic children's health. These results can serve as an evidence base for psychological nursing practice with asthmatic children.

Introduction

Asthma's increasing prevalence, severity, and associated medical costs have triggered interest in new physiological and psychological intervention strategies, including self-management (Guevara et al., 2003, Smith et al., 2005, Wolf et al., 2003), breathing-exercise techniques (Dennis, 2000, Ernst, 2000, Holloway and West, 2007), group and family therapy (Deter and Allert, 1983), and hypnosis (Kohen and Wynne, 1997). Educational and self-management programs have shown positive results in terms of reducing asthma signs/symptoms, school absenteeism, number of days of restricted activity, and improved lung function (Guevara et al., 2003). However, many studies have focused just on physiological health even when an intervention has both physiological and psychological components. Few studies have focused on treating children's psychological problems during the chronic illness period.

Stress and psychological factors have been shown by a growing body of evidence to trigger and exacerbate asthmatic conditions (for example, see Lehrer, 1998, Mathe and Knappe, 1971, Sandberg et al., 2000). Studies on the links between socio-environmental stressors, personality, and asthma attacks have shown that, regardless of the trigger, anxiety is a common reaction to asthmatic episodes. For example, asthmatic children have been described as reacting to stressful situations and emotional distress in terms of anxiety, depression, and irritability (Chiang, 2005, Juniper et al., 1996, Rydstrom et al., 1999). Recurring asthma attacks and asthma signs/symptoms have been shown to impact on children's psychosocial functions (Stores et al., 1997). Furthermore, almost one-third of all children with asthma meet the criteria for comorbid anxiety disorders (Katon et al., 2004), meaning that stress should be viewed as both a trigger and a consequence of this chronic disease. Asthma patients experience shortness of breath and a sensation of asphyxiation due to bronchial constriction, with simultaneously enhanced vagal drive, leading to an imbalance of sympathetic/parasympathetic influences. Various emotional states and stress increase oscillatory resistance. Stress can also exacerbate airway hyperactivity and airway inflammation in bronchial asthma. Parasympathetic nerve impulses lead to a slower heart rate, more regular respiration, and general relaxation (Lehrer, 1998).

Accordingly, Smith et al. (2005) argue that future research on psycho-educational interventions must consider the interaction of asthma and psychosocial factors. Similarly, more psychological intervention studies have been suggested, with outcome measurements including severity of asthma signs/symptoms, medication usage, and psychological indicators, such as anxiety (Pagliari et al., 2002). In clinical practice, the most popular psychological nursing intervention for all diseases is teaching relaxation-breathing techniques that emphasize using the mind–body connection for sign/symptom control (Kemper, 2000). This trend is based on empirical validation of the idea that changes in a patient's emotional status can influence immunological performance (Castes et al., 1999, Kern-Buell et al., 2000). For example, an intervention that combined relaxation teaching, guided imagery, and self-esteem techniques reduced the IgE response to primary allergens, increased the number of natural killer cells, and led to other positive changes in cell surface markers so that they resembled those of non-asthmatic children in identical environments (Castes et al., 1999). In one relaxation-training study involving 16 non-smoking and non-steroid-dependent asthma patients between the ages of 13 and 30, patients in the experimental group showed significant improvements in lung function (FEV₁/FVC) but not in immunologic function (Kern-Buell et al., 2000). These results provide inconsistent support for the effect of relaxation techniques on immunologic function. Moreover, the effects of relaxation training on psychological indicators for asthmatic children remain unknown.

Relaxation-based behavioral therapy was found in a meta-analysis of 31 psycho-educational programs conducted between 1972 and 1993 to exert moderately strong effects (effect size >0.35) on psychological health, attacks, lung function, and medication dosage of adult asthmatics (Devine, 1996). The effects of relaxation and disease-management techniques in clinical trials have been inconsistent in asthmatic adults (Davis et al., 1973, Devine, 1996, Erskine-Milliss and Schonell, 1981, Lehrer et al., 1992, Richter and Dahme, 1982) and in children (Alexander et al., 1979, Kotses et al., 1978, McQuaid and Nassau, 1999, Scherr et al., 1975, Vazquez and Buceta, 1993a, Vazquez and Buceta, 1993b). Relaxation training has been shown to make positive contributions to asthma management, but Ritz (2001) suggested that studies in this area have generally been poorly designed. On the other hand, others (Huntley et al., 2002) concluded that insufficient evidence supports a role for relaxation therapies in assisting asthma management, but acknowledged positive effects in terms of muscular relaxation and improved lung function. Furthermore, a combined self-management and relaxation-training program for asthmatic children did not significantly change pulmonary function variables (Vazquez and Buceta, 1993a, Vazquez and Buceta, 1993b). Relaxation techniques have a positive effect on autonomic balance (Lehrer, 1998). Thus, relaxation techniques might stimulate parasympathetic nerve impulses and lead to a slower heart rate, more regular respiration, and general relaxation (Lehrer, 1998).

It is important to note that the efficacy of asthma-management techniques has been measured by a significant number of researchers using only physiological indicators—that is, their results do not directly address psychological indicators. When studying asthma management in children and adolescents, psychosocial interventions should be emphasized (Malhi, 2001), and intervention studies that address physiological, behavioral, and psychological variables provide evidence in support of holistic nursing approaches to this chronic disease. Indeed, relaxation training of 46 school-aged children successfully reduced levels of anxiety (Lamontagne et al., 1985). Furthermore, levels of dysphasia were reduced in 17 children and adolescents (ages 8–18) who were taught a relaxation technique based on self-induced hypnosis (Ran, 2001).

Based on this background, the purpose of the present study was to examine the effectiveness of teaching a combination of self-management and relaxation-breathing techniques to children with moderate-to-severe asthma. The results from an experimental intervention (self-management plus relaxation training) were compared with results from the self-management-only program currently favored by Taiwanese asthma clinics. Outcome measures were anxiety, perceived health status, asthma signs/symptoms, peak expiratory flow rate (PEFR), and asthma medication usage. The two hypotheses tested were as follows:

• Changes in physiological and psychological outcome measures between pre- and post-intervention are the same for both the experimental and comparison groups (i.e., the group × time interaction is not significant).

• Physiological and psychological outcome measures do not change in either group from pre- to post-intervention (i.e., the self-management program does not have a significant time effect).