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International Journal of Nursing Studies 46 (2009) 1061–1070

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Effect of relaxation-breathing training on anxiety and asthma

signs/symptoms of children with moderate-to-severe asthma:
A randomized controlled trial
Li-Chi Chiang a,*, Wei-Fen Ma a, Jing-Long Huang b, Li-Feng Tseng c, Kai-Chung Hsueh d
School of Nursing, China Medical University and China Medical University Hospital, Taichung 40402, Taiwan, ROC
Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Children’s Hospital and Chang Gung University,
Taoyuan, Taiwan, ROC
National Taichung Institute of Technology, Department of General Education, Taichung, Taiwan, ROC
Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan, ROC


Article history: Background: Emotional stress triggers and exacerbates asthma in children. Reducing
Received 14 August 2008 anxiety in adults by relaxation-breathing techniques has been shown in clinical trials to
Received in revised form 12 January 2009 produce good asthma outcomes. However, more evidence is needed on using this
Accepted 24 January 2009
intervention with asthmatic children.
Objective: To evaluate the effectiveness of combined self-management and relaxation-
Keywords: breathing training for children with moderate-to-severe asthma compared to self-
management-only training.
Design: Two-group experimental design.
Relaxation-breathing training Setting and participants: Pediatric outpatient clinic of a medical center in central Taiwan.
Chronic illness Participants were 48 children, ages 6–14 years, with moderate-to-severe asthma and their
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.
ß 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?

* Corresponding author. Tel.: +886 4 22053366x7119;

 Self-management programs can reduce asthma signs/
fax: +886 426310776. symptoms, school absenteeism, number of days of
E-mail address: lichi514@seed.net.tw (L.-C. Chiang). restricted activity, and can improve lung function.

0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
1062 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070

 Relaxation-breathing training has been suggested to sympathetic/parasympathetic influences. Various emo-

increase asthmatic children’s immunologic function and tional states and stress increase oscillatory resistance.
improve asthma signs/symptoms and health status, yet Stress can also exacerbate airway hyperactivity and airway
previous studies had inconsistent results and did not inflammation in bronchial asthma. Parasympathetic nerve
include psychological effects. impulses lead to a slower heart rate, more regular
 Relaxation-breathing training could be used in children respiration, and general relaxation (Lehrer, 1998).
to reduce their anxiety but no reports could be found for Accordingly, Smith et al. (2005) argue that future
its use in children with asthma. research on psycho-educational interventions must con-
sider the interaction of asthma and psychosocial factors.
What this paper adds Similarly, more psychological intervention studies have
been suggested, with outcome measurements including
 Relaxation-breathing training combined with a self- severity of asthma signs/symptoms, medication usage, and
management program for children with asthma did not psychological indicators, such as anxiety (Pagliari et al.,
significantly change their self-perceived health status, 2002). In clinical practice, the most popular psychological
asthma signs/symptoms, lung function, and medication nursing intervention for all diseases is teaching relaxation-
usage compared to the self-management group. breathing techniques that emphasize using the mind–body
 Relaxation-breathing training combined with a self- connection for sign/symptom control (Kemper, 2000). This
management program lowered children’s anxiety, which trend is based on empirical validation of the idea that
in turn might help children maintain good psychological changes in a patient’s emotional status can influence
health. immunological performance (Castes et al., 1999; Kern-
Buell et al., 2000). For example, an intervention that
1. Introduction combined relaxation teaching, guided imagery, and self-
esteem techniques reduced the IgE response to primary
Asthma’s increasing prevalence, severity, and asso- allergens, increased the number of natural killer cells, and
ciated medical costs have triggered interest in new led to other positive changes in cell surface markers so
physiological and psychological intervention strategies, that they resembled those of non-asthmatic children in
including self-management (Guevara et al., 2003; Smith identical environments (Castes et al., 1999). In one
et al., 2005; Wolf et al., 2003), breathing-exercise relaxation-training study involving 16 non-smoking and
techniques (Dennis, 2000; Ernst, 2000; Holloway and non-steroid-dependent asthma patients between the ages
West, 2007), group and family therapy (Deter and Allert, of 13 and 30, patients in the experimental group showed
1983), and hypnosis (Kohen and Wynne, 1997). Educa- significant improvements in lung function (FEV1/FVC) but
tional and self-management programs have shown posi- not in immunologic function (Kern-Buell et al., 2000).
tive results in terms of reducing asthma signs/symptoms, These results provide inconsistent support for the effect of
school absenteeism, number of days of restricted activity, relaxation techniques on immunologic function. Moreover,
and improved lung function (Guevara et al., 2003). the effects of relaxation training on psychological indica-
However, many studies have focused just on physiological tors for asthmatic children remain unknown.
health even when an intervention has both physiological Relaxation-based behavioral therapy was found in a
and psychological components. Few studies have focused meta-analysis of 31 psycho-educational programs con-
on treating children’s psychological problems during the ducted between 1972 and 1993 to exert moderately strong
chronic illness period. effects (effect size >0.35) on psychological health, attacks,
Stress and psychological factors have been shown by a lung function, and medication dosage of adult asthmatics
growing body of evidence to trigger and exacerbate (Devine, 1996). The effects of relaxation and disease-
asthmatic conditions (for example, see Lehrer, 1998; management techniques in clinical trials have been incon-
Mathe and Knappe, 1971; Sandberg et al., 2000). Studies sistent in asthmatic adults (Davis et al., 1973; Devine, 1996;
on the links between socio-environmental stressors, Erskine-Milliss and Schonell, 1981; Lehrer et al., 1992;
personality, and asthma attacks have shown that, regard- Richter and Dahme, 1982) and in children (Alexander et al.,
less of the trigger, anxiety is a common reaction to 1979; Kotses et al., 1978; McQuaid and Nassau, 1999; Scherr
asthmatic episodes. For example, asthmatic children have et al., 1975; Vazquez and Buceta, 1993a,b). Relaxation
been described as reacting to stressful situations and training has been shown to make positive contributions to
emotional distress in terms of anxiety, depression, and asthma management, but Ritz (2001) suggested that studies
irritability (Chiang, 2005; Juniper et al., 1996; Rydstrom in this area have generally been poorly designed. On the
et al., 1999). Recurring asthma attacks and asthma signs/ other hand, others (Huntley et al., 2002) concluded that
symptoms have been shown to impact on children’s insufficient evidence supports a role for relaxation therapies
psychosocial functions (Stores et al., 1997). Furthermore, in assisting asthma management, but acknowledged
almost one-third of all children with asthma meet the positive effects in terms of muscular relaxation and
criteria for comorbid anxiety disorders (Katon et al., 2004), improved lung function. Furthermore, a combined self-
meaning that stress should be viewed as both a trigger and management and relaxation-training program for asthmatic
a consequence of this chronic disease. Asthma patients children did not significantly change pulmonary function
experience shortness of breath and a sensation of variables (Vazquez and Buceta, 1993a,b). Relaxation tech-
asphyxiation due to bronchial constriction, with simulta- niques have a positive effect on autonomic balance
neously enhanced vagal drive, leading to an imbalance of (Lehrer, 1998). Thus, relaxation techniques might stimulate
L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1063

parasympathetic nerve impulses and lead to a slower heart were recruited from patients at the asthma clinic by a well-
rate, more regular respiration, and general relaxation trained research assistant (RA). Children were included in
(Lehrer, 1998). the study if they met these criteria: (1) diagnosed with
It is important to note that the efficacy of asthma- moderate-to-severe asthma by a physician at least 6
management techniques has been measured by a sig- months before the study, (2) had >5 asthmatic episodes
nificant number of researchers using only physiological per year, with an Aas score of 2 (Aas, 1981), and (3)
indicators—that is, their results do not directly address regularly treated with asthma medication in a pediatric
psychological indicators. When studying asthma manage- clinic. Children were excluded if they had participated in
ment in children and adolescents, psychosocial interven- any other clinical trials. Potential participants were given a
tions should be emphasized (Malhi, 2001), and complete description of the study. Those who agreed to
intervention studies that address physiological, beha- participate provided written informed consent.
vioral, and psychological variables provide evidence in The Aas asthma severity score is a 5-step clinical score
support of holistic nursing approaches to this chronic that assesses the frequency and duration of asthma attacks
disease. Indeed, relaxation training of 46 school-aged during the previous year (Aas, 1981). A score of 1 (mild
children successfully reduced levels of anxiety (Lamon- asthma) indicates <5 asthma attacks, each lasting <7 days,
tagne et al., 1985). Furthermore, levels of dysphasia were and no functional limitation. A score of 2 (moderate
reduced in 17 children and adolescents (ages 8–18) who asthma) indicates <10 attacks, each lasting <7 days, and
were taught a relaxation technique based on self-induced no functional limitation. A score of 3 (moderate asthma)
hypnosis (Ran, 2001). indicates >10 attacks, each lasting <7 days, and no
Based on this background, the purpose of the present functional limitation. A score of 4 (severe asthma)
study was to examine the effectiveness of teaching a indicates >5 attacks, chronic cough, and hospitalization.
combination of self-management and relaxation-breath- A score of 5 indicates chronic malfunctioning asthma,
ing techniques to children with moderate-to-severe acute exacerbation, and the need for continuous medica-
asthma. The results from an experimental intervention tion treatment. Therefore, an asthmatic child with an Aas
(self-management plus relaxation training) were com- asthma severity score >2 has had >5 attacks in the
pared with results from the self-management-only pro- previous year.
gram currently favored by Taiwanese asthma clinics. To provide high quality care, all participating children
Outcome measures were anxiety, perceived health status, and parents received the medical center’s routine asthma
asthma signs/symptoms, peak expiratory flow rate (PEFR), self-management program and an asthma-management
and asthma medication usage. The two hypotheses tested teaching booklet. After receiving the asthma self-manage-
were as follows: ment program, children and parents in the experimental
group also received relaxation training in a separate room.
1. Changes in physiological and psychological outcome In general, matching is used to make sure that
measures between pre- and post-intervention are the participants in various research groups are equivalent on
same for both the experimental and comparison groups one or more characteristics (Polit and Beck, 2005). The
(i.e., the group  time interaction is not significant). characteristics previously found to influence asthma self-
2. Physiological and psychological outcome measures do management, physical activity, and quality of life were
not change in either group from pre- to post-interven- gender (Chiang et al., 2006a,b), age (young children or pre-
tion (i.e., the self-management program does not have a adolescents) (Miles et al., 1995), and asthma severity
significant time effect). (Chiang et al., 2006a,b). Therefore, children were randomly
assigned to the experimental or comparison groups using a
2  2  3 randomized block design (2 genders, 2 age ranges
2. Methods
(6–10 and 11–14 years old), and 3 asthma severity scores (2,
2.1. Design 3, 4) (Aas, 1981)). This randomization procedure was
confidentially conducted by an administrator in the clinic.
A two-group experimental design was used to evaluate The first eligible child was assigned by a coin toss to the
the effectiveness of relaxation-breathing training com- experimental or comparison group using the block
bined with a self-management program in children with randomization scheme. If the first child was a girl, aged
asthma. Children in both the experimental and comparison 6–10 with an Aas score of 3, she would be randomly
groups received explanations of asthma disease, asthma assigned by coin toss into the experimental or comparison
medication, and monitoring with peak flow meters, but group. Then the next girl, aged 6–10 with an Aas score of 3,
only those in the experimental group received relaxation- would be assigned to the other group. The assignment
breathing training. Interventions lasted for 12 weeks per continued until all participants were assigned to each
participant, with data for five outcome indicators collected group. This procedure removed the variance due to gender,
at the beginning and end of each intervention. age, and asthma severity from the error term, increasing
the power of the study. A list of treatment assignments
2.2. Participants linked with case number was generated and kept by the
first author and the study statistician. The codes and
All asthmatic children who participated in this study treatment assignments were not released to any subjects,
were recruited from the pediatric asthma clinic of a staff, and pediatric physicians other than those mentioned
medical center in central Taiwan. Potential participants until the completion of data analysis.
1064 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070

Of the 65 families who met the inclusion criteria, 3 and SDs were obtained from a small pilot study. Placing
families refused to participate or their questionnaires were these values into the following formula (Muellner, 2002):
incomplete at pre-test. From the remaining 62 families, 29 ðz1 þ z2 Þ2 ðs21 þ s22 Þ
children were randomly assigned to the experimental nðper groupÞ ¼
ðm1  m2 Þ2
group and 33 children to the comparison group. Another
three families in the experimental group did not complete produced an overall sample size of 40, with 20 in each
the asthma self-management program and relaxation group.
training. Unfortunately, four families in the experimental The children who dropped out and participating
group and seven families in the comparison group were children were not significantly different in terms of gender
lost to the 3-month follow-up. Thus, the final sample (x2 = 0.677, p = 0.513), age (x2 = 0.250, p = 0.720), and Aas
included 22 children in the experimental group and 26 in score (x2 = 2.471, p = 0.291). Because of dropouts, it was
the comparison group (Fig. 1). necessary to check the homogeneity of the two groups in
Our power analysis, based on Cohen (1992) suggested terms of gender, age, and asthma severity. This analysis
criteria for comparing the means of two groups with a large showed no significant differences between the experi-
effect size and a = 0.05, indicated that the necessary mental and comparison groups (Table 1).
sample size was 26 for each group. Although 59 children
were recruited for the study, 11 families dropped out. The 2.3. Interventions
sample size was then re-calculated using the following
parameter values: Type I error of 5% (z1 = 1.96), power of The comparison and experimental groups received
80% (z2 = 0.842), mean values (m1 = 17.00 and m2 = 11.00), different interventions: only the routine self-management
and standard deviations (s1 = 7.0 and s2 = 6.8). The means program offered by a graduate nurse student after medical

Fig. 1. The flowchart of recruiting.

L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1065

Table 1 relaxation were recorded in a relaxation CD and one-page

Demographic characteristics of the experimental and comparison groups.
instruction sheet provided to parents, who were taught
Experimental Comparison x2 p how to coach their child to practice relaxation at home. The
group (n = 22) group asthmatic children easily followed directions on the CD
(n = 26)
and practiced every day at home.
n % n % To ensure that the participating children were capable
Gender of achieving a state of relaxation, the entire sequence of
Male 15 68.2 15 57.7 0.559 0.328 muscle contraction–relaxation was recorded using bio-
Female 7 31.8 11 42.3 physiological (biofeedback) software. Children’s relaxation
Asthma severitya was scored by the research assistant using the Behavioral
2 5 22.7 5 19.2 Relaxation Scale (Raymer and Poppen, 1985) and frontal
3 9 40.9 12 46.2 0.155 0.545 electromyogram. All children were also requested to self-
4 8 36.4 9 34.6
report their level of relaxation on the Relaxation Visual
Age (years) Analogue Scale (Norton et al., 1997). Parents and children
6–10 16 72.7 20 76.9 0.112 0.498 were contacted once per week by telephone to encourage
11–14 6 27.3 6 23.1
regular practice. During the 12-week intervention, parti-
Emotion-induced asthma cipants practiced relaxation for 30 min at least three times
Yes 5 22.7 4 15.4 0.422 0.389 per week. Some of the pre-adolescents practiced relaxation
No 17 77.3 22 84.6
by themselves, but most young children practiced with
Asthma severity in the previous year determined by Aas score (Aas,
their parents.
1981): 2 indicates moderate asthma with <10 attacks, each lasting <7
days, and no functional limitation; 3 indicates moderate asthma with >10
attacks, each lasting <7 days, and no functional limitation; 4 indicates 2.4. Ethical considerations
severe asthma with >5 attacks, chronic cough, and hospitalization.
This study was approved by the Institutional Review
center’s asthma clinic, and the routine self-management Board of China Medical University Hospital (DMR92-IRB-
program plus relaxation-breathing training, respectively. 027). Parents were also given an informed consent
agreement emphasizing the voluntary nature of their
2.3.1. Self-management program participation, explaining their right to leave the study at
After collecting baseline data, the first author and a any time, and giving study details. Copies of signed
nursing graduate student used a case-management model agreements were retained by the research assistant and
(Tzeng and Chiang, 2005) to implement the self-manage- parents.
ment education program to children in both groups. This
program has five units: (a) reforming asthma cognition, (b) 2.5. Data collection
correct usage of asthma drugs, (c) establishing a safe home
environment, (d) monitoring with a peak flow meter, and Data were collected on anxiety, self-perceived health
(e) keeping an asthma diary. Parents were given an status, asthma signs/symptoms, PEFR, and asthma medica-
educational booklet on personal care plans, peak flow tion with instruments commonly used in Taiwan to measure
meter records (with one meter given to each family), and children’s anxiety and associated health indicators.
using a diary to record asthma signs/symptoms.
2.5.1. Anxiety
2.3.2. Relaxation-breathing training Anxiety was measured using the Chinese Children’s
At the end of the self-management program for all Anxiety Scale (CCAS; Lin et al., 1973), which has been used
participants, children and their parents in the experi- in several studies involving Chinese children and adoles-
mental group received 30 min of relaxation-breathing cents (ages 6–19). The CCAS has 66 dichotomous items
training. In this training, which is based on a technique divided into the 37-item Chinese Children’s Manifest
developed by Jacobson (Titlebaum, 1988), children were Anxiety Scale (CCMAS) and the 29-item General Anxiety
coached to relax 15 muscle groups in progression, with Scale for Chinese Children (GASCC). Total anxiety scores
regular deep breathing. The researcher directs children to range from 0 to 66, with higher scores indicating greater
sit comfortably in a quiet room for 5 min, tense a group of anxiety. The CCMAS is based on the Children’s Manifest
muscles, such as those in the right arm, hold the Anxiety Scale (Castaneda et al., 1956), which was originally
contraction for about 8 s, and relax the muscle group for designed to assess the level and nature of anxiety in
about 30 s while breathing out. After a short rest, this children and adolescents ages 6–19 years. The CCMAS is
sequence is repeated with another set of muscles. The used to measure children’s general tendency to anxiety.
muscle sequence was right foot, right lower leg and foot, The GASCC is based on the General Anxiety Scale for
entire right leg, left foot, left lower leg and foot, entire left Children (Sarason et al., 1960), which was originally
leg, right hand, right forearm and hand, entire right arm, designed to measure trait anxiety. The current Chinese
left hand, left forearm and hand, entire left arm, abdomen, version was designed to measure emotional responses to
chest, neck and shoulders, and face. Through repetitive specific situations. The overall CCAS has been shown to
practice, patients learn to recognize the feelings associated have adequate internal consistency, content validity, and
with a tensed muscle and a completely relaxed muscle. construct validity when used with Taiwanese children (Lin
This process and the sequence of progressive muscle et al., 1973). In a re-examination of the reliability and
1066 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070

validity of the CCAS (Tseng, 1993) the test–retest reliability medication once per week over 4 weeks received 1 point
for the CCMAS was 0.78 and for the GASCC was 0.72 for and more than twice per week 2 points, 2 use theophylline
boys and 0.76 for girls. or Singullair1 received 2 points, and use of an oral steroid
received between 3 and 5 points (3 for <3–5 days/4 weeks,
2.5.2. Self-perceived health status 4 for 6–10 days, and 5 for >10 days).
Self-perceived health status was measured by four
items adapted from the Perceived Health Status Scale 2.6. Data analysis
(Kaplan and Camacho, 1988). Responses to items were
measured on a 5-point Likert scale from 1 (very bad) to 5 All data were analyzed (descriptive and inferential
(very good). In this study, internal consistency (Cronbach’s statistics) using SPSS (12.0) for Windows. Demographic data
a) was 0.71. of the experimental and comparison groups were compared
using Chi-Square analysis. The SPSS Mixed Model was used to
2.5.3. Asthma signs/symptoms analyze scores for anxiety, self-perceived health status,
The signs/symptoms checklist used in this study was asthma signs/symptom, medication usage, and PEFR for
modified from an asthma symptom diary (Santanello et al., differences between the two groups and within each group
1999). The checklist includes four items: ability to sleep at over the 12-week intervention. To reduce problems in
night (1 item) and daytime symptoms of persistent repeated measurements, the mixed model technique is
coughing, wheezing, and dyspnea (3 items). Responses better than the General Linear Model in overcoming missing
to items were recorded by parents on a 4-point scale data in some variables at follow-up and limited availability of
according to the frequency of asthma signs/symptoms. variance–covariance structures (Chan, 2004). These types of
Lower scores indicate better control of asthma signs/ designs are called mixed-model ANOVAs, since they involve
symptoms. In this study, internal consistency (Cronbach’s a mixture of one between-groups factor and one within-
a) was 0.71. groups factor. This type of analysis is better than traditional
analysis, i.e., a two-way ANOVA, which combines one
2.5.4. Peak expiratory flow rate (PEFR) independent-sample factor and one correlated-group factor.
PEFR was measured in participating children twice each
day using Astech1 peak flow meters (Dey, L.P., Napa, CA),
3. Results
which are used in Taiwanese asthma clinics. PEFR is
recorded as the best of three trials. Results from spirometric 3.1. Participant characteristics
measures indicated a Pearson correlation r = 0.313
(p < 0.05) between PEFR and the score on the asthma In the final sample of 48 children and their parents, 22
signs/symptoms checklist used in this study and r = 0.682 were in the experimental group, and 26 were in the
(p < 0.001) between PEFR and FEV1 by Micro-Medical Super comparison group. Both groups had a majority of boys
Spiro CE120, SN1141. The children were trained in the self- (experimental: 68.2%; comparison: 57.7%), consistent with
management program to correctly use the PEF meter. the high prevalence of boys having asthma (Chiang et al.,
2007). Each group also had a majority (experimental:
2.5.5. Asthma medication usage 72.7%; comparison: 76.9%) of young children (6–10 years
Use of asthma medications was assessed by the Asthma old) and a minority (experimental: 22.7%; comparison:
Medication score, based on a treatment ladder established 15.4%) of children with emotion-induced asthma (Table 1).
according to Global Initiative for Asthma guidelines
(National Heart, Lung and Blood Institute, 2007). Higher 3.2. Outcome variables
scores indicate greater dosage and/or stronger asthma
medications. Scores for participants in this study ranged Data for each variable at the beginning and end of the
from 0 to 14, with scoring methods focused on monthly 12-week intervention are presented in Table 2. Psycholo-
drug dose. Use of a prophylactic medication in the gical indicators (total anxiety) for the experimental group
preceding month received 1 point, use of a beta-agonist decreased on average over the 12-week intervention (from

Table 2
Descriptive statistics for pre- and post-intervention outcomes for asthmatic children.

Variable Pre-intervention Post-intervention

Experimental group Comparison group Experimental group Comparison group

n Mean (SD) n Mean (SD) n Mean (SD) n Mean (SD)

Children’s anxiety 22 31.73 (12.27) 23 29.96 (11.96) 18 26.11 (11.41) 19 32.21 (17.76)
CCMASa 22 16.64 (6.86) 23 14.74 (7.37) 18 12.67 (7.15) 19 15.77 (10.45)
GASCCb 22 15.09 (6.57) 23 15.22 (6.02) 16 13.88 (6.08) 19 16.21 (8.64)
Health status 22 15.19 (3.20) 26 15.43 (3.80) 20 18.55 (3.39) 17 17.82 (4.02)
Asthma signs/symptoms 22 9.46 (2.11) 26 10.44 (1.95) 20 6.93 (1.51) 17 7.24 (1.71)
PEFR 22 227.05 (71.69) 26 186.73 (46.80) 20 282.50 (76.72) 17 240.12 (63.62)
Asthma medication 20 5.10 (3.34) 18 4.17 (2.68) 20 2.75 (2.84) 18 1.94 (2.18)
CCMAS: Chinese Children’s Manifest Anxiety Scale.
GASCC: General Anxiety Scale for Chinese Children.
L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1067

a score of 31.73–26.11), but increased on average for the post-intervention in the experimental group than in the
comparison group (29.96–32.21). Tendency to anxiety comparison group (by 5.62/2.25 and 3.97/1.03, respec-
(CCMAS scores) in the experimental group was decreased tively). However, trait anxiety (GASCC) scores did not differ
on average (16.64–12.67), but increased in the comparison significantly between groups. The results indicate that
group (14.74–15.77). children in the experimental group had significantly less
Physiological indicators improved for both groups total anxiety than their comparison group counterparts
over the 12-week interventions. Specifically, health status (t = 2.27, p < 0.05). Therefore, relaxation-breathing train-
improved (15.19–18.55 in the experimental group; 15.43– ing appears to have exerted a positive effect on general
17.82 in the comparison group), asthma signs/symptoms tendency to anxiety but not on trait anxiety.
were reduced (9.46–6.93 in the experimental group; Physiological indicators improved after the 12-week
10.44–7.24 in the comparison group), PEFR increased interventions in both groups (health status: t = 2.70,
(227.05–282.50 in the experimental group; 186.73–240.12 p < 0.01; asthma signs/symptoms: t = 5.84, p < 0.001;
in the comparison group), and less asthma medication was PEFR: t = 4.00, p < 0.001; asthma medication usage:
used (5.10–2.75 in the experimental group; 4.17–1.94 in t = 3.03, p < 0.01). However, the group  time interaction
the comparison group). was not significant for any of the four physiological
The results from Mixed Model analyses are shown in variables (health status, asthma signs/symptoms, PEFR,
Table 3. Total anxiety and general tendency to anxiety asthma medication) although improvement over time was
(CCMAS) scores changed significantly more from pre- to evident for both groups (Table 4).

Table 3
Mixed Model evaluation of the effect of relaxation-breathing technique on anxiety.

Outcome variable b SE t p 95% confidence interval

Upper Lower

Children’s anxiety
Experimental group (comparison group) 7.44 4.33 1.72 0.091 16.10 1.22
Pre-intervention (post-intervention) 2.68 2.83 0.95 0.347 8.34 2.98
Group  time interaction 9.21 4.05 2.27 0.027 1.11 17.32

Experimental group (comparison group) 4.07 2.52 1.62 0.111 9.10 0.97
Pre-intervention (post-intervention) 1.55 1.61 0.96 0.340 4.78 1.67
Group  time interaction 5.96 2.51 2.58 0.012 1.34 10.59

Experimental group (comparison group) 3.44 2.15 1.60 0.115 7.74 0.86
Pre-intervention (post-intervention) 1.08 1.50 0.72 0.475 4.07 1.92
Group  time interaction 3.31 2.13 1.56 0.124 0.93 7.56

Mixed model with fixed gender effect as covariance.

Experimental group = 0, comparison group = 1, pre-intervention = 1, post-intervention = 2.
CCMAS: Chinese Children’s Manifest Anxiety Scale.
GASCC: General Anxiety Scale for Chinese Children.

Table 4
Mixed Model evaluation of the effect of relaxation-breathing technique on physiological outcomes.

Outcome variable b SE t p 95% confidence interval

Upper Lower

Health status
Experimental group (comparison group) 0.52 1.18 0.45 0.657 1.83 2.88
Pre-intervention (post-intervention) 2.59 0.95 2.70 0.009 4.50 0.68
Group  time interaction 0.77 1.33 0.58 0.567 3.42 1.89

Asthma signs/symptoms
Experimental group (comparison group) 0.28 0.61 0.46 0.644 1.50 0.93
Pre-intervention (post-intervention) 3.23 0.55 5.84 <0.000 2.13 4.33
Group  time interaction 0.70 0.77 0.90 0.369 2.24 0.84

Experimental group (comparison group) 39.14 20.35 1.92 0.059 1.51 79.78
Pre-intervention (post-intervention) 55.07 13.77 4.00 <0.000 82.57 27.57
Group  time interaction 1.18 18.97 0.06 0.951 36.72 39.07

Asthma medication
Experimental group (comparison group) 0.81 0.91 0.88 0.381 1.02 2.63
Pre-intervention (post-intervention) 2.22 0.73 3.03 0.004 0.75 3.69
Group  time interaction 0.13 1.01 0.13 0.900 1.90 2.15

Mixed model with fixed gender effect as covariance.

Experimental group = 0, comparison group = 1, pre-intervention = 1, post-intervention = 2.
1068 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070

4. Discussion very comfortable, especially following the directions on

the relaxation CD. One 10-year-old girl mentioned, ‘‘My
Our study results indicate that relaxation-breathing mother’s presence during my relaxation practice allowed
training combined with a self-management program can me to feel my parents’ love and care, and that really helped
improve both physiological indicators (self-perceived me to remain calm.’’ Previous nursing interventions or
health status, asthma signs/symptoms, PEFR, and reliance relaxation-training programs were conducted in hospital
on asthma medications) and psychological indicators or in a laboratory (Vazquez and Buceta, 1993a,b). To
(anxiety) for children with moderate-to-severe asthma. translate the practice into the routine of life, we trained
Health care providers rightly emphasize the physiological parents to coach their children in using the relaxation
aspects of asthma, but in this disease, as with all chronic technique at home and telephoned to remind them to
diseases, it is important to acknowledge the potential for practice regularly every night. The results revealed that
long-term psychological influences. For children with relaxation-breathing could reduce children’s anxiety and
moderate and severe asthma, high-quality nursing care prevent further psychological problems. This improved
needs to include efforts to promote psychological adapta- psychological status may lead to better nursing care and
tion to the disease. Our findings are consistent with those improve outcomes for children with asthma.
reported in other studies of the effects of self-management Future nurse-led psycho-education interventions for
interventions in children with asthma (Guevara et al., children with asthma require more investigation to
2003; Smith et al., 2005; Wolf et al., 2003). The data also promote high quality care in biological, psychological,
indicate that children in the experimental group received and sociological health for children with a chronic disease.
not only the benefit of improved physiological health but
also reduced anxiety. 4.1. Limitations
The high prevalence of anxiety in the participating
children is consistent with previous findings (Katon et al., This study and its findings have at least three
2004). The data suggest that children’s anxiety increases limitations. First, the sample was limited in terms of
over time if not treated by a health care provider. recruiting children from a single hospital, although doing
Specifically, the results indicate a change in general so reduced the potential for contaminated data and
tendency to anxiety but not in trait anxiety, which is supported internal validity. Cooperation of the parents
thought to be a relatively stable personality disposition and children was required for training in the relaxation
and a predictor of state anxiety (Li and Lopez, 2005). In the technique. Everyday practice depended on the total
present study, the nursing intervention of relaxation- cooperation of participants, making the study difficult to
breathing training affected children’s perceived anxiety. implement. For example, over the 12-week intervention,
Over time, the practice of relaxation breathing might some parents did not think that recording data in their
change trait anxiety more than transitory emotional diaries was necessary because their children went through
reactions. For children with moderate or severe asthma, a period of few or mild asthma attacks. Other parents
much more time and effort are required to teach them self- stated that they were too tired at night to encourage their
management and relaxation strategies that will mitigate children to practice relaxation, and a few families started
emotional distress (Rydstrom et al., 1999). Proper training visiting other clinics for their health care needs. Despite
of asthmatic children and their parents may also require these difficulties, which resulted in some drop-out, most
overcoming psychological barriers that can negatively participants in this study adhered to the study protocol.
influence disease management (Pagliari et al., 2002). Furthermore, guidelines for sample size (Green, 1990)
Therefore, future studies should extend relaxation training suggest that similarity in dropout rates for the two groups
for asthmatic children and assess long-term effects on did not necessitate canceling the entire study, and the
psychological and physiological outcomes. added factor of relaxation-breathing training for the
The results from the present study are inconsistent with experimental group did not influence decisions to drop
previous reports that relaxation-breathing training posi- out of the study. Second, to make data collection
tively affected physiologic-immunological interactions convenient for nurses, laboratory measures of IgE and
and physiological indicators. Specifically, the lack of a pulmonary function (spirometries for FEV1/FVC) were not
positive effect of the combined self-management and determined. Third, the data collection instruments were
relaxation-breathing training on signs/symptoms or lung long, requiring a great deal of time and effort from the
function is consistent with the findings of Vazquez and participating children. This raises not only the issue of
Buceta (1993a,b) and Kohen and Wynne (1997), but not participant burden, but also questions regarding socially
with those of Kern-Buell et al. (2000). Accordingly, the desirable responses.
effects of relaxation-breathing techniques on psychologi-
cal and physiological indicators among asthma patients 4.2. Conclusion and clinical implications
require further clarification.
Although not part of the study, some of the qualitative The results suggest that a combination of asthma self-
data from interviews with parents and asthmatic children management and relaxation-breathing training can posi-
give insights into their perceptions of practicing relaxation tively affect the physiological and psychological health of
techniques. Many children claimed that practicing relaxa- children with moderate-to-severe asthma. Relaxation-
tion every night enabled them to feel very relaxed, calm, breathing training is a simple intervention that pediatric
and to fall asleep easily. The deep breathing exercises were nurses can implement independently. However, guidelines
L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1069

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Conflict of interest
Katon, W.J., Richardson, L., Lozano, P., McCauley, E., 2004. The relation-
None declared. ship of asthma and anxiety disorders. Psychosomatic Medicine 66,
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