Handbook of Psychology

Psychological Interventions for Asthma 113

history of emotional triggers. Participants without emotional
triggers showed greater changes on this measure without re-
laxation instruction. At a borderline signi“cant level, partici-
pants given relaxation training showed a greater decrease in
consumption of beta-2 adrenergic stimulant (rescue) medica-
tions than those not given relaxation training. However, on
measures of pulmonary function, participants with emotional
asthma triggers bene“ted signi“cantly from asthma educa-
tionwithoutrelaxation, but notwith it. The authors hypothe-
sized these subjects may have put less emphasis on proper
medical management of asthma. Thus, relaxation training
may only be bene“cial for asthma patients with emotionally-
triggered symptoms.

Biofeedback Techniques

EMG Biofeedback

Kotses and his colleagues (Glaus & Kotses, 1983; Kotses et al.,
1991) hypothesized that changes in facial muscle tension di-
rectly produce respiratory impedance through a trigeminal-
vagal re”ex pathway (such that tensing these muscles produces
bronchoconstriction, while relaxing them produces bronchodi-
lation). They tested the model using frontal EMG biofeedback
to increase and decrease tension in the facial muscles. Frontal
EMG relaxation training was found to decrease facial muscle
tension and to produce improvements in pulmonary function,
while training to increase tension in this area had the opposite
effect. EMG biofeedback training to the forearm muscles had
no effects. Several studies from other laboratories have failed
to replicate these “ndings, however (Lehrer et al., 1994, 1996;
Lehrer, Generelli, & Hochron, 1997; Mass, Wais, Ramm, &
Richter, 1992; Ritz, Dahme, & Wagner, 1998).
Another biofeedback strategy, suggested by Peper and his
colleagues, linked pulmonary function with tension in the
skeletal muscles of the neck and thorax (Peper & Tibbetts,
1992). (Tension in this area often is produced by a pattern of
thoracic breathing.) They used EMG biofeedback training to
teach participants to relax these muscles, while simultane-
ously increasing volume and smoothness of breathing. This
training was done in the context of a multi-component treat-
ment that included desensitization to asthma sensations and
training in slow diaphragmatic breathing. The latter training
was carried out by a biofeedback procedure using an incen-
tive inspirometer. At the follow-up, all subjects signi“cantly
reduced their EMG tension levels while simultaneously
increasing their inhalation volumes. Subjects reported reduc-
tions in their asthma symptoms, medication use, emergency
room visits, and breathless episodes. A small study from our
laboratory did not show signi“cant ef fects for this method

(Lehrer, Carr, et al., 1997), but this study lacked power to

determine whether some trends in the data were signi“cant.

More research on this method is warranted.

Respiratory Resistance Biofeedback

Mass and his colleagues (1991) attempted to train subjects to

decrease respiratory resistance by providing continuous

biofeedback of this measure, using the forced oscillation

method. In an uncontrolled trial, this feedback technique

decreased average respiratory resistance within sessions but

not between sessions (Mass, Dahme, & Richter, 1993). It did

not increase FEV 1 (Mass, Richter, & Dahme, 1996). They

concluded that this type of biofeedback is not an effective

technique for the treatment of bronchial asthma in adults.

Respiratory Sinus Arrhythmia (RSA) Biofeedback

More recently, a novel biofeedback approach that utilizes the

phenomenon of respiratory sinus arrhythmia (RSA) has been

used to improve pulmonary function in asthma patients

(Lehrer, Carr, et al., 1997; Lehrer, Smetankin, & Potapova,

2000). In RSA, the increase and decrease in heart rate with in-

spiration and expiration, is mediated by vagal out”ow at the

sino-atrial node. Normally, the magnitude of heart rate vari-

ability at respiratory frequency is directly associated with

efferent vagal activity and may also be related to autonomic

regulatory control. A detailed manual for conducting this

procedure has been published (Lehrer, Vaschillo, & Vaschillo,

2000). In brief, patients utilize slow (approximately six

breaths per minute), abdominal, pursed-lips breathing to in-

crease the magnitude of RSA at their own particular optimal

respiratory frequency. Multiple case studies from clinics in

Russia support the hypothesis that RSA biofeedback training

is an effective treatment for various neurotic and stress-related

physical disorders (Chernigovskaya, Vaschillo, Petrash, &

Rusanovskii, 1990; Chernigovskaya, Vaschillo, Rusanov-

skii, & Kashkarova, 1990; Pichugin, Strelakov, & Zakhare-

vich, 1993; Vaschillo, Zingerman, Konstantinov, & Menitsky,

1983), and asthma (Lehrer, Smetankin, et al., 2000). Larger

scale, controlled clinical trials are currently underway to fur-

ther assess the effectiveness and therapeutic mechanisms of

this intervention.

Other Self-Regulation Methods

Yoga

Two studies of yoga among asthmatics found improvement

in asthma symptoms, as well as a more positive attitude,