|Year : 2018 | Volume
| Issue : 1 | Page : 19-24
Efficacy of progressive relaxation technique and yoga in patients with stress-induced asthma: A randomized controlled trial
S Veena Kirthika1, K Padmanabhan2, S Sudhakar3, CV Senthil Nathan4, S Ramachandran5
1 Department of Neuro Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Chennai, Tamil Nadu, India
2 Department of Ortho Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Chennai, Tamil Nadu, India
3 Department of Sports Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Chennai, Tamil Nadu, India
4 Department of Geriatric Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Chennai, Tamil Nadu, India
5 Department of Cardiopulmonary Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Chennai, Tamil Nadu, India
|Date of Web Publication||24-Jan-2018|
Dr. S Sudhakar
Department of Sports Physiotherapy, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute University, Maduravoyal, Chennai – 600095, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Asthma is a chronic inflammatory disorder of the airway. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, and coughing. Various physiotherapy techniques help in the reduction of symptoms associated with asthma which includes deep breathing exercises and relaxation postures. Progressive relaxation technique (PRT) is useful in reducing the respiratory symptoms and stress in asthma. Yoga techniques have shown clinically relevant improvements in their quality of life and effective reduction in the frequency of attacks and degree of stress. Objective: The objective of this study is to compare the effect of PRT and yoga in patients with stress-induced asthma (SIA) so that better treatment program can be adopted in the reduction of symptoms in participants with SIA. Methodology: Thirty participants with asthma were recruited for the study and were divided into two groups. Group A (n = 15) was treated with PRT and Group B (n = 15) was treated with yoga technique for a duration of 3 months. Outcome Measures: Asthma Quality of Life Questionnaire (AQOL) and Depression, Anxiety and Stress Scale (DASS) were used. Results: Group B (yoga group) showed a significant difference, P < 0.05 in the mean values of DASS and AQOL when compared to Group A (P > 0.05). Postyoga intervention, the patients with SIA demonstrated decrease in the symptoms of depression, anxiety, and stress, and increased quality of life. Conclusion: Three-month duration of yoga is more effective than PRT in patients with SIA in reducing asthmatic symptoms and improving quality of life.
Keywords: Asthma, depression, progressive relaxation technique, quality of life, stress, yoga
|How to cite this article:|
Kirthika S V, Padmanabhan K, Sudhakar S, Senthil Nathan C V, Ramachandran S. Efficacy of progressive relaxation technique and yoga in patients with stress-induced asthma: A randomized controlled trial. Muller J Med Sci Res 2018;9:19-24
|How to cite this URL:|
Kirthika S V, Padmanabhan K, Sudhakar S, Senthil Nathan C V, Ramachandran S. Efficacy of progressive relaxation technique and yoga in patients with stress-induced asthma: A randomized controlled trial. Muller J Med Sci Res [serial online] 2018 [cited 2018 Jun 21];9:19-24. Available from: http://www.mjmsr.net/text.asp?2018/9/1/19/223910
| Introduction|| |
Asthma is a chronic airway inflammation and increased airway hyper-responsiveness. Typical symptoms include wheeze, coughing, chest tightness, and dyspnea which are accompanied by the presence of airflow obstruction, variable over short periods of time, or reversible with treatment. The cause of asthma is unknown, but it is likely to be polygenic disease influenced by environmental factors.
Stress is an important trigger for asthma. Stress is part of daily life with or without asthma. Learning to relax feeling stressed can help prevent shortness of breath and avoid an asthma attack. Stress worsens and causes asthmatics to feel frightened. Stress-induced asthma (SIA) seems to be increasing in young individuals. Due to stress, their performance is reduced; it also leads to absenteeism and reduced levels of physical activity. Stress is the way the mind and body respond to the damaging and harmful situation, which arise due to change in the environment (mental and physical). Severity of stress depends on stressors which depend on individual's perception of stress and stressors. SIA leads to severe broncoconstriction.
Young individuals more frequently suffer from asthma associated with psychological stress. Stress-induced vagal reactivity is responsible for broncoconstriction in asthma. Emotional stress may sometimes trigger asthmatic exacerbation primarily because extreme expression of laughing, crying, anger, or fear leading to hyperventilation and hypercapnia than can cause airway narrowing. Various therapeutic techniques including progressive relaxation technique (PRT) and yoga play a significant role in relief and improving quality of life in SIAs. Regulating the breath regulates the mind, relaxes the physique as the breathe is the connecting link between mind and body. It leads to decreased adrenocortical activity, therefore increases ability to resist stress.
PRT was developed by Edmund Jacobson in the 1920s. In 1920, Jacobson published his findings in PRT. PRT consists of a series of exercises involving contracting a muscle group, holding the contraction then relaxing., Contraction teaches awareness to what muscle tension feels like. Relaxing the muscle teaches the absence of tension and how this can be voluntarily induced. PRT involves isometric contraction. Benefits of PRT help a person better able to deal with the stress, help to identify signs of stress, and reduce anxiety.
Yoga breathing is based on simple principles of pranayama and adho mukha svanasana. Pranayama is a Sanskrit word composed of the words, prana meaning vital life force and ayama meaning restraint. The word pranayama thus translates as the regulation or control of life force. Pranayama helps in silencing the mind, thereby regulating the rate and rhythm of respiration and facilitating energy conservation. It has great effects on obstructive lung diseases and asthma as it reduces and relieves bronchospasm, facilitates diaphragmatic relaxation, and aids in regulated rhythmic breathing., Adho mukha svanasana = adho (downward), mukha (face), svana (dog). This asana boosts self-confidence, improves cognition and brain function, reduces stress, depression, and anxiety, tones and strengthens legs, straightens arm, and lengthens the spine.
This study is an attempt to compare the effectiveness of two techniques, namely, PRT and yoga in patients with SIA.
| Methodology|| |
The study protocol was approved by the Institutional Ethics Committee, and the study was done in accordance to Helsinki Declaration, revised 2013. The two-group pre- and post-test design was carried between August 2016 and May 2017. This experimental study was done to compare the effectiveness of PRT and yoga on patients with SIA. A total of 30 patients with SIA were recruited for this randomized controlled trial by the simple random sampling (random tables from statistics book). Before enrollment into the study, they were asked to sign the informed consent and then anthropometric measurement was taken. By the block random allocation, the sample was allocated into two groups of 15 each. Group A was treated with PRT whereas Group B was given yoga. Depression, Anxiety and Stress Scale (DASS), and Asthma Quality of Life Questionnaire (AQOL),,, were measured before treatment and at the end of 3 months of treatment.
Progressive relaxation technique
PRT is an exercise that relaxes mind and body by progressively tensing and relaxing muscle groups throughout entire body. Tensing each muscle group vigorously, but without straining, and then suddenly release the tension and feel the muscle relax. Tense each muscle for about 5 s. If pain or discomfort occurs at any of the targeted muscle groups, avoid that step. Throughout this technique visualize the muscle tensing and a wave of relaxation flowing over them as releasing the tension. It is important to keep a good breathing pattern and concentrate on breathing throughout the exercise.
Patients were made in a comfortable position either sitting or lying down [Figure 1] in a location where the patients were not interrupted. Focus attention only on body, begin to notice mind wandering, bring back to the muscle working on. The patients were instructed to take a deep breath through the abdomen hold for a few seconds and exhale slowly. The following instructions were given. They were asked to notice their stomach raising and lungs filling with air. While exhaling, image the tension in body being released and flowing out of body. Then instructed to inhale and exhale. Feeling the body relaxing. As going through each step, remember to keep breathing. Tighten the muscle in forehead by raising eyebrows as high as they can. Hold for about 5 s and abruptly release of feeling the tension falling away. Pause for about 10 s. Now smile widely, feeling mouth and cheeks tense. Hold for about 5 s and release appreciating softness of face. Pause for about 10 s. Tighten eye muscle by squinting eyelids tightly shut. Hold for about 5 s, and release. Pause for about 10 s. Gently pull head back as to look at the ceiling. Hold for about 5 s. Feeling the tension melting away. Pause for about 10 s. Now flex the neck slowly and extend without straining. Breathe in and out. Clench the fists and hold this position for about 5 s. Now flex biceps and visualize the muscle tension hold for about 5 s. Pause for about 10 s. Tense upper back by pulling shoulders back trying to make shoulder blades touch. Hold for 5 s and release. Tighten buttock, curl toes, individually for about 5 s each and pause for 10 s. Lastly breathe in and out. The sequence of PRT is displayed in [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Yoga is a special form of physical exercise through mind control. The following yoga techniques were demonstrated and supervised by the lead author having 7 years' experience of teaching yoga to clients and 20 years' experience of practicing yoga.
Pranayama helps in silencing the mind, thereby regulating the rate and rhythm of respiration and facilitating energy conservation. Pranayama the perfect control over the mind and body can be reached by controlling the motion of the lungs and controlling the motion of the lungs is pranayama. Pranayama has great effects on obstructive lung disorders as it reduces and relaxes bronchospasm, facilitates diaphragmatic relaxation, and aids in regulated rhythmic breathing.
Pranayama is practiced with an empty stomach. Patients were made to sit in a comfortable place on a mat on the floor, with legs crossed, [Figure 6]. Spine (back) erect and straight, head straight, face looking forward, eyes closed with eyes pointing to nose tip. Sit quietly for 1 min. Breathe deeply, breathe easily. Take a deep breath (as deep as possible) very slowly and steadily, without hurrying up. Hold the breath for as long as comfortable. Exhale slowly. Exhaling period should be longer than inhaling period. Repeat the same steps from 1 to 3 for three to ten times, based on convenience. Duration not more than 2 min. Practiced daily once or twice a day.
Alternate nostril breathing (Nadi Shodhan Pranayama)
Patients were made in comfortable sitting position to sit quietly for 1 min and breathe deeply and easily. Take a deep breath with right nostril and exhaling through the left nostril alternatively. Repeat the same step from 1 to 3 for three to ten times. Duration not more than 2 min and practiced daily.
Same nostril breathing
Take a deep breath with right nostril and exhale through the same nostril. Repeat the same step for other nostril also and repeat the steps 1–3 for three to ten times with a duration not more than 2 min.
Adho mukha svanasana technique
Adho mukha svanasana or downward facing dog pose helps in calming the mind, relieves stress, and is good for suffering from asthma and sinusitis.
Participants were made in a comfortable position. Ask them to come into fours to form a table such that back forms the table top and hands and feet form the legs of the table. As they breathe out, lift the hips, straightening the knees and elbows, forming an inverted V-shape in the body. Hands are shoulder width apart; feet are hip width apart and parallel to each other. Toes point straight ahead. Press hands into the ground, widen through the shoulder blades, and keep the neck lengthened by touching the ears to the inner arms. Hold the downward dog pose and take long deep breaths, look toward the navel. Exhale, bend the knees, return to table pose and relax. The whole sequence is shown in [Figure 7]a,[Figure 7]b,[Figure 7]c. Repeat the steps 1–3 for three to ten times, not more than 2 min.
|Figure 7: (a) Adho mukha svanasana (starting position), (b) adho mukha svanasana (progression), (c) adho mukha svanasana (end position)|
Click here to view
The collected data were analyzed using descriptive and inferential statistics; mean ± standard deviation was used to assess all parameters of the data using the Statistical Package for the Social Science, IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Paired t-test was adopted to find the effectiveness within Group A and B in patients with SIA, and independent t-test was used to compare the changes in mean values of all parameters between Group A and Group B.
| Results|| |
On comparing mean values of Group A and B [Figure 8] on DASS, both the groups showed reduction in the posttest mean, but Group B demonstrated significantly (P< 0.001) lower mean values of depression (6.26 ± 0.3), anxiety (6.26 ± 0.5), and stress (11.53 ± 0.8), when compared to Group A of depression (11.2 ± 1.7), anxiety (11.2 ± 1.6), and stress (18.9 ± 1.9). Approximately 50% reduction in posttest value in Group B was compared to only 20% reduction in Group A. While comparing the mean values of Group A and Group B [Figure 9] on AQOL scores, both the groups showed increase in the posttest mean, but Group B demonstrated significantly (P = 0.03) higher mean value (6.6 ± 1.2) when compared to Group A (5.2 ± 0.9).
|Figure 8: Comparison of DASS scores between Group A and Group B in pre- and post-test values. DASS: Depression, Anxiety and Stress Scale|
Click here to view
|Figure 9: Comparison of AQOL scores between Group A and Group B in pre- and post-test values. AQOL: Asthma Quality of Life Questionnaire|
Click here to view
| Discussion|| |
The study was conducted on 30 patients with SIA, two groups of 15 each. Group A was treated with PRT whereas Group B was given yoga. DASS and AQOL were measured before treatment and at the end of 3 months of treatment. This comparative study was done to compare the effectiveness of two techniques, namely, PRT and yoga.
According to a German study which was conducted to determine the long-term effects of breathing exercises and yoga in patients with bronchial asthma demonstrated a significant improvement in mental state and lung parameters by breathing exercises when compared to yoga. This contradicts results of our study. Tandon conducted a study on 11 patients with severe chronic airway obstruction who were given training in yogic breathing exercises and postures. After treatment, the exercise tolerance improved in the yoga group and the ability to recover more quickly after exercise.
Lehrer states that an integral behavioral treatment consists of psychoeducation and progressive muscle relaxation which reduces the symptoms of panic attack. Pranayama and yogic postures used in this study were performed under the supervision of a qualified yoga master. The techniques used also have evidence from the literature. Both the techniques, namely, PRT and yoga used in this study were effective in reducing stress-related symptoms associated with asthma and improved the quality of life as per AQOL. When both the groups were compared, Group B (Yoga) showed a significant reduction in stress symptoms and improved quality of life in young SIAs.
This study implies that yoga might be an effective treatment program for patients with SIA. It has demonstrated improvement in quality of life, reduced stress, and might be adopted as a better treatment program.
| Conclusion|| |
The present study concluded that 3-month duration of yoga is more effective than PRT in patients with SIA by the reduction of asthmatic symptoms and improved the quality of life.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rees J. ABC of asthma. Definition and diagnosis. Br Med J (Clin Res Ed) 1984;288:1370-2.
Lommatzsch M, Virchow JC. Severe asthma: Definition, diagnosis and treatment. Dtsch Arztebl Int 2014;111:847-55.
Pride NB. Asthma. Definition and clinical spectrum. Br Med Bull 1992;48:1-9.
Rietveld S, Everaerd W, Creer TL. Stress-induced asthma: A review of research and potential mechanisms. Clin Exp Allergy 2000;30:1058-66.
Ohno I. Neuropsychiatry phenotype in asthma: Psychological stress-induced alterations of the neuroendocrine-immune system in allergic airway inflammation. Allergol Int 2017;66S:S2-8.
Kieffer M. Progressive relaxation. Dr. E. Jacobson's method. Bull Soc Sci Med Grand Duche Luxemb 1978;115:83-7.
Kohl F. Progressive muscle relaxation according to E. Jacobson. A modern relaxation technique. Med Monatsschr Pharm 2002;25:77-87.
Conrad A, Roth WT. Muscle relaxation therapy for anxiety disorders: It works but how? J Anxiety Disord 2007;21:243-64.
Field T. Yoga research review. Complement Ther Clin Pract 2016;24:145-61.
Agnihotri S, Kant S, Kumar S, Mishra RK, Mishra SK. Impact of yoga on biochemical profile of asthmatics: A randomized controlled study. Int J Yoga 2014;7:17-21.
] [Full text]
Wise J. Yoga may improve asthma symptoms, cochrane review finds. BMJ 2016;353:i2462.
Yang ZY, Zhong HB, Mao C, Yuan JQ, Huang YF, Wu XY, et al.
Yoga for asthma. Cochrane Database Syst Rev 2016;4:CD010346.
Henry JD, Crawford JR. The short-form version of the depression anxiety stress scales (DASS-21): Construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005;44:227-39.
Sinclair SJ, Siefert CJ, Slavin-Mulford JM, Stein MB, Renna M, Blais MA, et al.
Psychometric evaluation and normative data for the depression, anxiety, and stress scales-21 (DASS-21) in a nonclinical sample of U.S. Adults. Eval Health Prof 2012;35:259-79.
Juniper EF, Buist AS, Cox FM, Ferrie PJ, King DR. Validation of a standardized version of the asthma quality of life questionnaire. Chest 1999;115:1265-70.
Everhart RS, Smyth JM, Santuzzi AM, Fiese BH. Validation of the asthma quality of life questionnaire with momentary assessments of symptoms and functional limitations in patient daily life. Respir Care 2010;55:427-32.
Flüge T, Richter J, Fabel H, Zysno E, Weller E, Wagner TO. Long-term effects of breathing exercises and yoga in patients with bronchial asthma. Pneumologie. 1994 Jul;48(7):484-90. German (Abstract).
Tandon MK. Adjunct treatment with yoga in chronic severe airways obstruction. Thorax 1978;33:514-7.
Lehrer PM, Hochron SM, Mayne T, Isenberg S, Carlson V, Lasoski AM, et al.
Relaxation and music therapies for asthma among patients prestabilized on asthma medication. J Behav Med 1994;17:1-24.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]