Benefits and problems of a physical training programme for asthmatic patients

High-intensity aerobic exercise training improves exercise capacity, dyspnea, and fatigue in patients with severe asthma using triple inhaler

Objectives

Asthma is a chronic respiratory disease that affects millions of people worldwide and causes severe symptoms such as wheezing, coughing, and breathing difficulty. Despite modern treatments, 3%-10% of patients develop severe asthma, which requires high-dose medications, and they may still experience frequent and severe symptoms, exacerbations, and psychological impacts. This study aimed to investigate the effects of high-intensity aerobic exercise training (HIAET) in patients with severe asthma.

Materials and Methods

Patients with severe asthma were recruited, and cardiopulmonary exercise tests, dyspnea, and leg fatigue scores were performed before HIAET. Participants underwent a 12-week hospital-based HIAET, which involved exercising twice weekly to reach 80% of their peak oxygen uptake (VO2).

Results

Eighteen patients with severe asthma underwent HIAET, which resulted in significant improvement in peak VO2 (1214.0 ± 297.9-1349.4 ± 311.2 mL/min, P = 0.004) and work rate (80.6 ± 21.2-96.2 ± 24.8 watt, P < 0.001) and decrease in dyspnea (5.1 ± 1.8-4.1 ± 1.2, P = 0.017) and fatigue scores (5.2 ± 2.3-4.0 ± 1.2, P = 0.020) at peak exercise. No significant changes were observed in spirometry results, respiratory muscle strength, or circulatory parameters.

Conclusion

HIAET can lead to improved exercise capacity and reduced dyspnea and fatigue scores at peak exercise without changes in spirometry, respiratory muscle strength, and circulatory parameters.

Physical training in adults with asthma: An integrative approach on strategies, mechanisms, and benefits

Asthma is a chronic airway disease characterized by airflow limitation and respiratory symptoms associated with chronic airway and systemic inflammation, bronchial hyperreactivity (BHR), and exercise-induced bronchoconstriction (EIB). Asthma is a heterogeneous disease classified according to distinct airway and systemic inflammation. Patients commonly present with several comorbidities, including anxiety, depression, poor sleep quality, and reduced physical activity levels. Individuals with moderate to severe asthma often have more symptoms and difficulty achieving adequate clinical control, which is associated with poor quality of life, despite proper pharmacological treatment. Physical training has been proposed as an adjunctive therapy for asthma. Initially, it was suggested that the effect of physical training might be attributed to the improved oxidative capacity and reduced production of exercise metabolites. However, in the last decade, there has been evidence that aerobic physical training promotes anti-inflammatory effects in asthma patients. Physical training improves BHR and EIB, asthma symptoms, clinical control, anxiety, and depression levels, sleep quality, lung function, exercise capacity, and dyspnea perception. Furthermore, physical training reduces medication consumption. The most commonly used exercise strategies are moderate aerobic and breathing exercises; however, other techniques, such as high-intensity interval training, have shown promising effects. In the present study, we reviewed the strategies and beneficial effects of exercise on clinical and pathophysiological asthma outcomes.

Pulmonary rehabilitation versus usual care for adults with asthma

BACKGROUND

Asthma is a respiratory disease characterised by variable airflow limitation and the presence of respiratory symptoms including wheeze, chest tightness, cough and/or dyspnoea. Exercise training is beneficial for people with asthma; however, the response to conventional models of pulmonary rehabilitation is less clear.

OBJECTIVES

To evaluate, in adults with asthma, the effectiveness of pulmonary rehabilitation compared to usual care on exercise performance, asthma control, and quality of life (co-primary outcomes), incidence of severe asthma exacerbations/hospitalisations, mental health, muscle strength, physical activity levels, inflammatory biomarkers, and adverse events.

SEARCH METHODS

We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from their inception to May 2021, as well as the reference lists of all primary studies and review articles.

SELECTION CRITERIA

We included randomised controlled trials in which pulmonary rehabilitation was compared to usual care in adults with asthma. Pulmonary rehabilitation must have included a minimum of four weeks (or eight sessions) aerobic training and education or self-management. Co-interventions were permitted; however, exercise training alone was not.  DATA COLLECTION AND ANALYSIS: Following the use of Cochrane's Screen4Me workflow, two review authors independently screened and selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. We contacted study authors to retrieve missing data. We calculated between-group effects via mean differences (MD) or standardised mean differences (SMD) using a random-effects model. We evaluated the certainty of evidence using GRADE methodology.

MAIN RESULTS

We included 10 studies involving 894 participants (range 24 to 412 participants (n = 2 studies involving n > 100, one contributing to meta-analysis), mean age range 27 to 54 years). We identified one ongoing study and three studies awaiting classification. One study was synthesised narratively, and another involved participants specifically with asthma-COPD overlap. Most programmes were outpatient-based, lasting from three to four weeks (inpatient) or eight to 12 weeks (outpatient). Education or self-management components included breathing retraining and relaxation, nutritional advice and psychological counselling. One programme was specifically tailored for people with severe asthma.  Pulmonary rehabilitation compared to usual care may increase maximal oxygen uptake (VO2 max) after programme completion, but the evidence is very uncertain for data derived using mL/kg/min (MD between groups of 3.63 mL/kg/min, 95% confidence interval (CI) 1.48 to 5.77; 3 studies; n = 129) and uncertain for data derived from % predicted VO2 max (MD 14.88%, 95% CI 9.66 to 20.1%; 2 studies; n = 60). The evidence is very uncertain about the effects of pulmonary rehabilitation compared to usual care on incremental shuttle walk test distance (MD between groups 74.0 metres, 95% CI 26.4 to 121.4; 1 study; n = 30). Pulmonary rehabilitation may have little to no effect on VO2 max at longer-term follow up (9 to 12 months), but the evidence is very uncertain (MD -0.69 mL/kg/min, 95% CI -4.79 to 3.42; I2 = 49%; 3 studies; n = 66). Pulmonary rehabilitation likely improves functional exercise capacity as measured by 6-minute walk distance, with MD between groups after programme completion of 79.8 metres (95% CI 66.5 to 93.1; 5 studies; n = 529; moderate certainty evidence). This magnitude of mean change exceeds the minimally clinically important difference (MCID) threshold for people with chronic respiratory disease. The evidence is very uncertain about the longer-term effects one year after pulmonary rehabilitation for this outcome (MD 52.29 metres, 95% CI 0.7 to 103.88; 2 studies; n = 42). Pulmonary rehabilitation may result in a small improvement in asthma control compared to usual care as measured by Asthma Control Questionnaire (ACQ), with an MD between groups of -0.46 (95% CI -0.76 to -0.17; 2 studies; n = 93; low certainty evidence); however, data derived from the Asthma Control Test were very uncertain (MD between groups 3.34, 95% CI -2.32 to 9.01; 2 studies; n = 442). The ACQ finding approximates the MCID of 0.5 points. Pulmonary rehabilitation results in little to no difference in asthma control as measured by ACQ at nine to 12 months follow-up (MD 0.09, 95% CI -0.35 to 0.53; 2 studies; n = 48; low certainty evidence). Pulmonary rehabilitation likely results in a large improvement in quality of life as assessed by the St George's Respiratory Questionnaire (SGRQ) total score (MD -18.51, 95% CI -20.77 to -16.25; 2 studies; n = 440; moderate certainty evidence), with this magnitude of change exceeding the MCID. However, pulmonary rehabilitation may have little to no effect on Asthma Quality of Life Questionnaire (AQLQ) total scores, with the evidence being very uncertain (MD 0.87, 95% CI -0.13 to 1.86; 2 studies; n = 442). Longer-term follow-up data suggested improvements in quality of life may occur as measured by SGRQ (MD -13.4, 95% CI -15.93 to -10.88; 2 studies; n = 430) but not AQLQ (MD 0.58, 95% CI -0.23 to 1.38; 2 studies; n = 435); however, the evidence is very uncertain. One study reported no difference between groups in the proportion of participants who experienced an asthma exacerbation during the intervention period. Data from one study suggest adverse events attributable to the intervention are rare.  Overall risk of bias was most commonly impacted by performance bias attributed to a lack of participant blinding to knowledge of the intervention. This is inherently challenging to overcome in rehabilitation studies.  AUTHORS' CONCLUSIONS: Moderate certainty evidence shows that pulmonary rehabilitation is probably associated with clinically meaningful improvements in functional exercise capacity and quality of life upon programme completion in adults with asthma. The certainty of evidence relating to maximal exercise capacity was very low to low. Pulmonary rehabilitation appears to confer minimal effect on asthma control, although the certainty of evidence is very low to low. Unclear reporting of study methods and small sample sizes limits our certainty in the overall body of evidence, whilst heterogenous study designs and interventions likely contribute to inconsistent findings across clinical outcomes and studies. There remains considerable scope for future research.

A Meta Analysis of Physical Exercise on Improving Lung Function and Quality of Life Among Asthma Patients

Objective

This paper aims to perform a systematic assessment of the influence of physical exercise on asthma patients and discuss the intervention effects of different exercises on the lung function FEV1 (%pred) and quality of life among asthma patients so as to lay a scientific foundation for improving asthma symptoms.

Methods

Both Chinese and English databases were retrieved, including PubMed, Web of Science, Embase, The Cochrane Library, CBM, CNKI, Wan Fang Data, and VIP, whose retrieval period started from the founding date of each database to 1st, November 2021. Randomized controlled trials (RCT) studying the symptom indicators of asthma patients were collected. Those collected papers were screened according to the Inclusion Criteria and Exclusion Criteria. Then, methodological quality assessments were conducted on the included papers, and combined effect sizes were analyzed by using software ReMan 5.3.5.

Results

The meta analysis showed that physical exercise could significantly improve lung function FEV1 (%pred) and quality of life score. Trails containing breathing exercise are the main source of heterogeneity, and the subgroup of breathing exercise may have better performance than the subgroup of aerobic exercise in improving FEV1 (%pred).

Conclusion

Physical exercise can significantly improve the symptoms and quality of life of asthma patients. Except the breathing exercise that showed heterogeneity, the subgroup of aerobic exercise could improve the capacity of FEV1 (%pred) more effectively, which led to a significant difference in the influence of quality of life. However, with regard to the gymnastic exercise including breathing exercise, there are limited same intervention methods and insufficient same outcome indicators. Therefore, more precise and high-quality researches are needed to make deeper verification in the future.

Influences of Breathing Exercises and Breathing Exercise Combined with Aerobic Exercise on Changes in Basic Spirometry Parameters in Patients with Bronchial Asthma

Scientific evidence shows that breathing or aerobic programs can improve the quality of life of asthma patients. The aim of this work was to find out the influences of breathing exercises and breathing exercises combined with aerobic exercise on changes in spirometry parameters in patients with bronchial asthma. Participants: The group consisted of 33 women with bronchial asthma—mild to moderate persistent levels of FEV1 reduction (80–50%)—with a mean age of 34.73 ± 1.53 years. They were randomly assigned to experimental group 1 (EX1), experimental group 2 (EX2) or the control group (CG). Materials and methods: Changes in spirometry parameters were evaluated over a 16-week period in the three groups: CG (placebo), EX1 (breathing exercises) and EX 2 (combination of breathing exercises with an aerobic program). To evaluate the pre-training and post-training diagnostics, we used MIR Spirobank II. The influences of the experimental and control factors were assessed using the following dependent variables: forced vital capacity (FVC), forced expiratory volume in one second (FEV1), Tiffeneau–Pinelli index (FEV1/FVC ratio), peak expiratory flow (PEF) and forced mid-expiratory flow (FEF25–75%). We used the Wilcoxon t-test and the Kruskal–Wallis test to evaluate the differences in the measured parameters. To examine the effect of our protocols, we used effect size (ES). Results: In CG we observed improvements in: FVC—(5%; p < 0.05; ES = 0.437). FEV1—(7.33%; p < 0.01; ES = 0.585). FEV1/FVC ratio (5.27%; p < 0.01; ES = 0.570). PEF (11.22%; p < 0.01; ES = 0.448). FEF25–75% (7.02%; p < 0.01; ES = 0.628). In EX1 we observed improvements in: FVC (5.23%; p < 0.01; ES = 0.631), FEV1 (20.67%; p < 0.01; ES = 0.627), FEV1/FVC ratio (16.06%; p < 0.01; ES = 0.628), PEF (13.35%; p < 0.01; ES = 0.627) and FEF25–75% (13.75%; p < 0.01; ES = 0.607). In EX2 we observed improvements in: FVC (9.12%; p < 0.01; ES = 0.627), FEV1 (27.37%; p < 0.01; ES = 0.626), FEV1/FVC ratio (15.32%; p < 0.01; ES = 0.610), PEF (30.66%; p < 0.01; ES = 0.626) and FEF25–75% (58.99%; p < 0.01; ES = 0.626). Significant differences compared to the control group were observed in EX1 for FEV1 (p < 0.05) and FEV1/FVC ratio (p < 0.01); and in EX2 for FEV1 (p < 0.05), FEV1/FVC ratio (p < 0.01), PEF (p < 0.05) and FEF (p < 0.05). A significant difference between EX1 and EX2 was observed in PEF (p < 0.05). Conclusions: It appears to be that combination of breathing exercises with aerobic activities is a more beneficial option for patients with bronchial asthma.

Effects of exercise-based pulmonary rehabilitation on adults with asthma: a systematic review and meta-analysis

BACKGROUND

Pulmonary rehabilitation (PR) has been proposed as an effective method for many respiratory diseases. However, the effects of exercise-based PR on asthma are currently inconclusive. This review aimed to investigate the effects of exercise-based PR on adults with asthma.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science, International Clinical Trials Registry Platform and ClinicalTrials.gov databases were searched from inception to 31 July 2019 without language restriction. Randomized controlled trials (RCTs) investigating the effects of exercise-based PR on adults with asthma were included. Study selection, data extraction and risk of bias assessment were performed by two investigators independently. Meta-analysis was conducted by RevMan software (version 5.3). Evidence quality was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

Ten literatures from nine studies (n = 418 patients) were identified. Asthma quality of life questionnaire total scores (MD = 0.39, 95% CI: 0.02 to 0.76) improved significantly in the experimental group compared to control group, including activity domain scores (MD = 0.58, 95% CI: 0.21 to 0.94), symptom domain scores (MD = 0.52, 95% CI: 0.19 to 0.85), emotion domain scores (MD = 0.53, 95% CI: - 0.03 to 1.09) and environment domain scores (MD = 0.56, 95% CI: 0.00 to 1.11). Both the 6-min walk distance (MD = 34.09, 95% CI: 2.51 to 65.66) and maximum oxygen uptake (MD = 4.45, 95% CI: 3.32 to 5.58) significantly improved. However, improvements in asthma control questionnaire scores (MD = - 0.25, 95% CI: - 0.51 to 0.02) and asthma symptom-free days (MD = 3.35, 95% CI: - 0.21 to 6.90) were not significant. Moreover, there was no significant improvement (MD = 0.10, 95% CI: - 0.08 to 0.29) in forced expiratory volume in 1 s. Nonetheless, improvements in forced vital capacity (MD = 0.23, 95% CI: 0.08 to 0.38) and peak expiratory flow (MD = 0.39, 95% CI: 0.21 to 0.57) were significant.

CONCLUSIONS

Exercise-based PR may improve quality of life, exercise tolerance and some aspects of pulmonary function in adults with asthma and can be considered a supplementary therapy. RCTs of high quality and large sample sizes are required.

CLINICAL TRIAL REGISTRATION

The review was registered with PROSPERO (The website is https://www.crd.york.ac.uk/prospero/ , and the ID is CRD42019147107).

Can training induce inflammatory control in asthma, or is it symptom control only?

PURPOSE OF REVIEW

Exercise has shown to reduce asthma symptoms; however, the underlying mechanism for this improvement remains unclear. Improvement in inflammatory control could be the reason for this reduction in symptoms. This review discusses recent studies evaluating the effect of exercise on inflammatory control in patients with asthma.

RECENT FINDINGS

New studies support that exercise is well tolerated and feasible regardless of intensity. Exercise seems to improve systemic low-grade inflammation, but consistency lacks when it comes to reduction in airway inflammation.

SUMMARY

Physical exercise as an adjuvant therapy leads to improvement in asthma symptoms and asthma-related quality of life and should be recommended for all patients with asthma.

Effects of continuous aerobic exercise on lung function and quality of life with asthma: a systematic review and meta-analysis

Background

Despite the obvious benefits of aerobic exercise for asthmatic patients, controversies persist. The current study evaluated the effectiveness of continuous aerobic exercise on lung function and quality of life of asthmatic patients.

Methods

We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials databases up to May 2019 and included randomized controlled trials (RCTs) of asthmatic patients intervened with whole body continuous aerobic exercise (moderate intensity, at least 20 minutes and two times a week, over a minimum period of four weeks), in which the endpoint measures were lung function and asthma-related quality of life. A fixed-effects model (I²≤50%) or random-effects model (I²>50%) was applied to calculate the pooled effects according to the I²-and Chi-squared (χ²) test, funnel plots were quantified to present publication bias, and a P value <0.05 was statistically significant.

Results

Eventually, 22 trials conformed to the selection criteria. In the aerobic exercise group, the forced expiratory volume improved in one second (FEV1) (I²=10.2%, WMD: 0.12, P=0.011), peak expiratory flow (PEF) (I²=87.3%, WMD: 0.66, P=0.002), forced vital capacity (FVC) (I²=0.0%, WMD: 0.18, P<0.001), FVC/predict (I²=3.9%, WMD: 4.3, P=0.014), forced expiratory flow between 25% and 75% of vital capacity (FEF_25-75%) (I²=0.0%, WMD: 9.6, P=0.005), Asthma Quality of Life Questionnaire (AQLQ) (I²=0.0%, WMD: 0.20, P=0.002), and Pediatric Asthma Quality of life Questionnaire (PAQLQ) (I²=72.1%, WMD: 0.81, P<0.001), respectively, while no statistical significance existed in FEV1%predict (I²=36.0%, WMD: 0.68, P=0.312) and FEV1/FVC ratio (I²=0.0%, WMD: 0.27, P=0.443) compared with the control group. When the exercise mode was taken into account, we observed significant improvement in FEV1, PEF, and FVC in the swimming (P<0.05) or indoor treadmill (P<0.05) training group.

Conclusions

Our meta-analysis proved that regular continuous aerobic exercise benefits asthma patients on FEV1, PEF, FVC, FVC%pred, FEF_25-75%, and quality of life, and was well tolerated, while there were no improvements in FEV1%pred and FEV1/FVC%. As such, swimming and treadmill training may be appropriate options.

Effect of aerobic exercise training on asthma in adults: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of aerobic exercise training on asthma control, lung function and airway inflammation in adults with asthma.

DESIGN

Systematic review and meta-analysis.

METHODS

Randomised controlled trials investigating the effect of ≥8 weeks of aerobic exercise training on outcomes for asthma control, lung function and airway inflammation in adults with asthma were eligible for study. MEDLINE, Embase, CINAHL, PEDro and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to April 3, 2019. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

We included 11 studies with a total of 543 adults with asthma. Participants' mean (range) age was 36.5 (22-54) years; 74.8% of participants were female and the mean (range) body mass index was 27.6 (23.2-38.1) kg·m^-2. Interventions had a median (range) duration of 12 (8-12) weeks and included walking, jogging, spinning, treadmill running and other unspecified exercise training programmes. Exercise training improved asthma control with a standard mean difference (SMD) of -0.48 (-0.81--0.16). Lung function slightly increased with an SMD of -0.36 (-0.72-0.00) in favour of exercise training. Exercise training had no apparent effect on markers of airway inflammation (SMD -0.03 (-0.41-0.36)).

CONCLUSIONS

In adults with asthma, aerobic exercise training has potential to improve asthma control and lung function, but not airway inflammation.

Exercise and Asthma

Asthma is a chronic lower respiratory disease that is very common worldwide, and its incidence is increasing year by year. Since the 1970s, asthma has become widespread, with approximately 300 million people affected worldwide and about 250,000 people have lost their lives. Asthma seriously affects people's physical and mental health, resulting in reduced learning efficiency, limited physical activities, and decreased quality of life. Therefore, raising awareness of the risk of asthma and how to effectively treat asthma have become important targets for the prevention and management of asthma in recent years. For patients with asthma, exercise training is a widely accepted adjunct to drug-based and non-pharmacological treatment. It has been recommended abroad that exercise prescriptions are an important part of asthma management.

Exercise Training in Patients with Chronic Respiratory Diseases: Are Cardiovascular Comorbidities and Outcomes Taken into Account?-A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases (ILD) frequently suffer from cardiovascular comorbidities (CVC). Exercise training is a cornerstone intervention for the management of these conditions, however recommendations on tailoring programmes to patients suffering from respiratory diseases and CVC are scarce. This systematic review aimed to identify the eligibility criteria used to select patients with COPD, asthma or ILD and CVC to exercise programmes; assess the impact of exercise on cardiovascular outcomes; and identify how exercise programmes were tailored to CVC. PubMed, Scopus, Web of Science and Cochrane were searched. Three reviewers extracted the data and two reviewers independently assessed the quality of studies with the Quality Assessment Tool for Quantitative Studies. MetaXL 5.3 was used to calculate the individual and pooled effect sizes (ES). Most studies (58.9%) excluded patients with both stable and unstable CVC. In total, 26/42 studies reported cardiovascular outcomes. Resting heart rate was the most reported outcome measure (n = 13) and a small statistically significant effect (ES = -0.23) of exercise training on resting heart rate of patients with COPD was found. No specific adjustments to exercise prescription were described. Few studies have included patients with CVC. There was a lack of tailoring of exercise programmes and limited effects were found. Future studies should explore the effect of tailored exercise programmes on relevant outcome measures in respiratory patients with CVC.

Applying Multivariate Segmentation Methods to Human Activity Recognition From Wearable Sensors' Data

BACKGROUND

Time-resolved quantification of physical activity can contribute to both personalized medicine and epidemiological research studies, for example, managing and identifying triggers of asthma exacerbations. A growing number of reportedly accurate machine learning algorithms for human activity recognition (HAR) have been developed using data from wearable devices (eg, smartwatch and smartphone). However, many HAR algorithms depend on fixed-size sampling windows that may poorly adapt to real-world conditions in which activity bouts are of unequal duration. A small sliding window can produce noisy predictions under stable conditions, whereas a large sliding window may miss brief bursts of intense activity.

OBJECTIVE

We aimed to create an HAR framework adapted to variable duration activity bouts by (1) detecting the change points of activity bouts in a multivariate time series and (2) predicting activity for each homogeneous window defined by these change points.

METHODS

We applied standard fixed-width sliding windows (4-6 different sizes) or greedy Gaussian segmentation (GGS) to identify break points in filtered triaxial accelerometer and gyroscope data. After standard feature engineering, we applied an Xgboost model to predict physical activity within each window and then converted windowed predictions to instantaneous predictions to facilitate comparison across segmentation methods. We applied these methods in 2 datasets: the human activity recognition using smartphones (HARuS) dataset where a total of 30 adults performed activities of approximately equal duration (approximately 20 seconds each) while wearing a waist-worn smartphone, and the Biomedical REAl-Time Health Evaluation for Pediatric Asthma (BREATHE) dataset where a total of 14 children performed 6 activities for approximately 10 min each while wearing a smartwatch. To mimic a real-world scenario, we generated artificial unequal activity bout durations in the BREATHE data by randomly subdividing each activity bout into 10 segments and randomly concatenating the 60 activity bouts. Each dataset was divided into ~90% training and ~10% holdout testing.

RESULTS

In the HARuS data, GGS produced the least noisy predictions of 6 physical activities and had the second highest accuracy rate of 91.06% (the highest accuracy rate was 91.79% for the sliding window of size 0.8 second). In the BREATHE data, GGS again produced the least noisy predictions and had the highest accuracy rate of 79.4% of predictions for 6 physical activities.

CONCLUSIONS

In a scenario with variable duration activity bouts, GGS multivariate segmentation produced smart-sized windows with more stable predictions and a higher accuracy rate than traditional fixed-size sliding window approaches. Overall, accuracy was good in both datasets but, as expected, it was slightly lower in the more real-world study using wrist-worn smartwatches in children (BREATHE) than in the more tightly controlled study using waist-worn smartphones in adults (HARuS). We implemented GGS in an offline setting, but it could be adapted for real-time prediction with streaming data.

Impact of Lifestyle Interventions Targeting Healthy Diet, Physical Activity, and Weight Loss on Asthma in Adults: What Is the Evidence?

Unhealthy lifestyle factors such as poor diet quality, sedentary lifestyle, and obesity are associated with negative health consequences in asthma including poor asthma control, impaired quality of life, and greater health care utilization. Lifestyle modification is the cornerstone of behavioral treatments and has been effective in chronic diseases such as atherothrombotic vascular disease and diabetes. There is a critical need for lifestyle interventions in asthma care that address obesity and its intimately linked risk behaviors in terms of poor diet and physical inactivity. We present in this commentary the promising lifestyle interventions emerging in asthma care that target poor diet, physical inactivity and weight loss, the proposed mechanisms of these lifestyle interventions, and the critical need for guideline-concordant lifestyle interventions in asthma care.

Physical activity and lung function decline in adults with asthma: The HUNT Study

BACKGROUND AND OBJECTIVE

People with asthma may seek advice about physical activity. However, the benefits of leisure time physical activity on lung function are unclear. We investigated the association between leisure time physical activity and lung function decline in adults with asthma.

METHODS

In a population-based cohort study in Norway, we used multiple linear regressions to estimate the annual mean decline in lung function (and 95% CI) in 1329 people with asthma over a mean follow-up of 11.6 years. The durations of light and hard physical activity per week in the last year were collected by questionnaire. Inactive participants did not report any light or hard activity, while active participants reported light or hard activity.

RESULTS

The mean decline in forced expiratory volume in 1 s (FEV₁ ) was 37 mL/year among inactive participants and 32 mL/year in active participants (difference: -5 mL/year (95% CI: -13 to 3)). The mean decline in forced vital capacity (FVC) was 33 mL/year among inactive participants and 31 mL/year in active participants (difference: -2 mL/year (95% CI: -11 to 7)). The mean decline in FEV₁ /FVC ratio was 0.36%/year among inactive participants and 0.22%/year in active participants (difference: -0.14%/year (95% CI: -0.27 to -0.01)). The mean decline in peak expiratory flow (PEF) was 14 mL/year among the inactive participants and 10 mL/year in active participants (difference: -4 mL/year (95% CI: -9 to 1)).

CONCLUSION

We observed slightly less decline in lung function in physically active than inactive participants with asthma, particularly for FEV₁ , FEV₁ /FVC ratio and PEF.

Aerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trial

Background

The benefits of aerobic training for the main features of asthma, such as bronchial hyperresponsiveness (BHR) and inflammation, are poorly understood. We investigated the effects of aerobic training on BHR (primary outcome), serum inflammatory cytokines (secondary outcome), clinical control and asthma quality of life (Asthma Quality of Life Questionnaire (AQLQ)) (tertiary outcomes).

Methods

Fifty-eight patients were randomly assigned to either the control group (CG) or the aerobic training group (TG). Patients in the CG (educational programme+breathing exercises (sham)) and the TG (same as the CG+aerobic training) were followed for 3 months. BHR, serum cytokine, clinical control, AQLQ, induced sputum and fractional exhaled nitric oxide (FeNO) were evaluated before and after the intervention.

Results

After 12 weeks, 43 patients (21 CG/22 TG) completed the study and were analysed. The TG improved in BHR by 1 doubling dose (dd) (95% CI 0.3 to 1.7 dd), and they experienced reduced interleukin 6 (IL-6) and monocyte chemoattractant protein 1 (MCP-1) and improved AQLQ and asthma exacerbation (p<0.05). No effects were seen for IL-5, IL-8, IL-10, sputum cellularity, FeNO or Asthma Control Questionnaire 7 (ACQ-7; p>0.05). A within-group difference was found in the ACQ-6 for patients with non-well-controlled asthma and in sputum eosinophil and FeNO in patients in the TG who had worse airway inflammation.

Conclusions

Aerobic training reduced BHR and serum proinflammatory cytokines and improved quality of life and asthma exacerbation in patients with moderate or severe asthma. These results suggest that adding exercise as an adjunct therapy to pharmacological treatment could improve the main features of asthma.

Trial registration number

NCT02033122.

Physical inactivity and television-viewing time among Aboriginal adults with asthma: a cross-sectional analysis of the Aboriginal Peoples Survey

INTRODUCTION

The purpose of this analysis was to (1) determine the association between asthma and physical activity levels or sedentary time among Aboriginal adults, and (2) understand the influence of physical inactivity and sedentary time on health care use among Aboriginal adults with asthma.

METHODS

We analyzed 20 953 adults from the 2006 Aboriginal Peoples Survey. Those with self-reported physician-diagnosed asthma and a current prescription for asthma medication were considered to have current asthma. Insufficient physical activity was defined as < 3 hours/week of moderate to vigorous physical activity; high television screen time was defined as > 10 hours/week. Health care use was assessed using the number of health professional visits and overnight hospital stays.

RESULTS

Aboriginal adults with asthma were more likely to report high television-viewing time (OR = 1.16; CI: 1.11-1.22) and insufficient physical activity (OR = 1.15; CI: 1.10-1.20) than those without asthma. Those with asthma who reported high television-viewing time reported more health professional consults in the past 12 months (OR = 2.59; CI: 2.34-2.87), more overnight stays in hospital in the past year (OR = 1.95; CI: 1.82-2.08) and more overnight stays in the hospital in the past 5 years (OR = 1.13; CI: 1.07-1.18); results were less consistent for physical activity and health care use.

CONCLUSION

These findings suggest that Aboriginal adults with asthma are less active than their peers without asthma and that such a lifestyle may be associated with higher health care use. These findings have implications for physical activity promotion and sedentary behaviour strategies targeting Aboriginal adults with asthma.

Gender differences in objectively assessed physical activity in asthmatic and non-asthmatic children

OBJECTIVE

To compare objectively assessed physical activity levels, between asthmatic children and non-asthmatic controls.

METHODS

From a random community sample of 794 children aged 8-9 years, in a case-control design, 104 children with ever doctor's diagnosis of asthma and 99 non-asthmatic controls were recruited and had assessment of physical activity with biaxial accelerometers for 7 days.

RESULTS

Children with active (also reporting at least one episode of wheezing in the last 12 months) and inactive (no wheezing in past 12 months) asthma appeared to have similar physical activity and sedentary activity levels compared to non-asthmatic children. However, girls with active asthma had significantly lower moderate-to-vigorous physical activity (MVPA) levels than their peers with adjusted geometric mean ratio of 0.59 (95% CI: 0.369, 0.929, P-value = 0.024). No difference in physical and sedentary activity levels was observed between asthmatic and non-asthmatic boys. The difference between genders in the comparison of MVPA levels in asthmatics and controls was statistically significant (P-value of likelihood ratio test [LRT] for effect modification by gender = 0.034).

CONCLUSIONS

Unlike boys, girls with active asthma appear to be less active than their healthy peers, and this gender difference might explain the inconsistent evidence from previous reports on physical activity levels in asthmatic children. Further studies are needed to confirm the gender interaction in the childhood asthma-physical activity relation and the implications on current guidelines for physical exercise prescriptions in asthmatic children.

Maternal and paternal beliefs, support and parenting as determinants of sport participation of adolescents with asthma

RATIONALE

Few studies have examined determinants of physical activity in patients with chronic illnesses, like asthma. The aim of this study was to examine whether baseline maternal and paternal beliefs, support and parenting were associated with changes in sport participation of adolescents with asthma, and investigate the moderating effect of sex.

METHODS

In a population-based cohort study, during home visits in 2012 and 2013, 253 adolescents completed a questionnaire assessing their sport participation. Both parents reported their sport-specific parenting (support, general and asthma-specific beliefs, self-efficacy to encourage sport participation). The collected data was described using descriptive statistics. Path and multi-group analyses were used to examine whether baseline parental factors predicted change in adolescent sport participation, multi-group analyses examined the moderating effect of sex. For all analyses probability p value less than the accepted level of significance α = 0.05 (p < 0.05) were taken as significant effects.

RESULTS

Few parental factors associated with changes in sport participation of the adolescents, sex did not moderate the associations. In the fully adjusted models, only maternal asthma-specific beliefs about sport participation were significantly positively associated with change in adolescent sport participation.

CONCLUSION

Sport-specific parenting does not appear to be a determinant of sport participation in adolescents with asthma. Future research should consider other individual, social and environmental determinants to inform intervention development.

Sport club participation of adolescents with asthma: maternal factors and adolescent cognitions

RATIONALE

Sport participation is especially important for patients with asthma in that it decreases psychosocial and physiological problems associated with inactivity. However, adolescents with asthma seem to participate less in sports compared to their non-asthmatic peers. The current study tested the direct associations between maternal sport-specific factors and sport club participation of early adolescents with asthma and the indirect effect through adolescent's sport-specific cognitions.

METHODS

During home visits, 261 adolescents (aged 10-15) completed questionnaires about self-efficacy, beliefs regarding sport participation, and their actual sport club participation. Their mothers reported their sport-specific support, beliefs about offspring's and own sport participation, their own levels of physical activity, and their self-efficacy to stimulate offspring to participate in sports. Path analyses were used to examine the direct and indirect associations of maternal sport-specific factors with adolescents sport club participation via adolescent sport-specific cognitions.

RESULTS

Analyses showed that maternal sport-specific support (β = 0.20, P = 0.007) and self-efficacy to stimulate offspring to participate in sports (β = 0.20, P = 0.027) related positively to adolescents' sport club participation. Adolescents' self-efficacy (indirect effect = 0.09, SE = 3.01, P < 0.001) mediated the positive relation between maternal self-efficacy to stimulate offspring to participate in sport and adolescents' participation in sport clubs.

CONCLUSION

Maternal sport-specific factors related to adolescents' sport club participation directly and indirectly through adolescents' sport-specific cognitions. Intervention programs should focus on maternal sport-specific support and self-efficacy and adolescents' self-efficacy to increase sport participation of adolescents with asthma.

Effects of exercise training on airway hyperreactivity in asthma: a systematic review and meta-analysis

BACKGROUND

Although physical exercise is recommended for asthmatics, evidence on the effects of exercise on clinical key factors is still missing.

OBJECTIVES

We performed a systematic review and meta-analysis to determine the effect of exercise training (EXT) on quality of life (QoL), bronchial hyperresponsiveness (BHR), exercise-induced bronchoconstriction (EIB), lung function and exercise capacity, plus the factors affecting changes in QoL and exercise capacity in asthmatics after a period of EXT.

DATA SOURCES

A computerized search was conducted in MEDLINE, EMBASE, and CINAHL (last search on 15 November 2012), without language restriction, and references of original studies and reviews were searched for further relevant studies.

STUDY SELECTION

Two independent investigators screened full-text studies with asthmatic subjects undertaking EXT (defined as training for ≥7 days, ≥2 times per week, ≥5 training sessions in total) that assessed at least one of the following outcomes: QoL, airway hyperreactivity, forced expiratory volume in one second (FEV₁), peak expiratory flow (PEF), inflammatory parameters, exercise capacity, or exercise endurance. Potentially relevant studies were excluded if only respiratory muscle training, breathing exercises or yoga was performed, if asthmatic subjects with co-morbidities were investigated, if only data of mixed patient groups without separate results for asthmatics were presented, if training regimens were not sufficiently specified, if no numerical outcome data were presented, and if new long-term medication was introduced in addition to physical training. Of 500 potentially relevant articles, 13.4 % (67 studies including 2,059 subjects) met the eligibility criteria and were included for further analyses.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data extraction and risk of bias assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis of all randomized controlled trials (RCTs) was performed to determine the effect of EXT on asthma symptoms, BHR, EIB, FEV₁, exercise capacity and exercise endurance compared with control training. In addition, relative pre/post changes were analysed in all RCTs and controlled trials. Finally, multiple linear regression models were used to identify effects of relative changes in airway hyperreactivity (BHR or EIB), lung function (FEV₁ or PEF) and training hours on QoL and exercise performance.

RESULTS

In a total of 17 studies including 599 subjects, meta-analyses showed a significant improvement in days without asthma symptoms, FEV1 and exercise capacity while BHR only tended to improve. The analysis of relative within-group changes after EXT showed, however, significant improvements in QoL (17 %), BHR (53 %), EIB (9 %), and FEV1 (3 %) compared with control conditions. Multiple linear regression models revealed that changes in airway hyperreactivity and lung function significantly contributed to the change in QoL, while mainly the changes in airway hyperreactivity contributed to the change in exercise capacity.

CONCLUSION

EXT was shown to improve asthma symptoms, QoL, exercise capacity, BHR, EIB, and FEV1 in asthmatics and improvements in BHR explained part of the improvement in QoL and exercise capacity. Thus, physical activity should be recommended as a supplementary therapy to medication. However, more well controlled studies should be performed assessing the relationship of physical activity, QoL, airway hyperreactivity, lung function and especially airway inflammation as well as medication intake.

Home-based respiratory rehabilitation in adult patients with moderate or severe persistent asthma

OBJECTIVE

We assessed retrospectively the feasibility of a home-based respiratory rehabilitation (RR) program for asthmatics under optimal pharmacological treatment, as this type of care can reduce costs and offer a more patient-friendly approach for subjects with persistent asthma.

METHODS

Fifty-two patients with persistent asthma were recruited to the RR program (20 males, 32 females, 54 ± 11 (SD) years, forced expiratory volume in one second 71 ± 33% of predicted mean value, BMI 29.9 ± 7.9 kg/m(2)). This two-month protocol comprised education sessions, respiratory physiotherapy and an exercise training program at home and in groups supervised by an adapted physical activity instructor.

RESULTS

Thirty-nine patients completed the whole RR program, i.e. 25% dropout. The dropout rate was significantly higher with respect to younger patients in employment. The number of exacerbations decreased significantly during the year following the program, regardless of whether the patients had dropped out (p < 0.02) or not (p < 0.001). The distance walked during a 6-min walking test increased by 33 m (p < 0.001). Several indices measured during a cycle ergometer test increased significantly after RR: peak oxygen uptake (10%), oxygen uptake at ventilatory threshold (12%) and maximum load (19%), all at a similar maximum heart rate. Concerning quality of life assessment, the Short-Form-36 Item Health Survey revealed a non-significant improvement in the "health change" item after RR (p < 0.07).

CONCLUSIONS

This study demonstrates the potential of a home-based program in the treatment and rehabilitation of patients with asthma. Both functional and physiologic indices improved during the follow-up period.

Evidence-based risk assessment and recommendations for physical activity clearance: respiratory disease

The 2 most common respiratory diseases are chronic obstructive pulmonary disease (COPD) and asthma. Growing evidence supports the benefits of exercise for all patients with these diseases. Due to the etiology of COPD and the pathophysiology of asthma, there may be some additional risks of exercise for these patients, and hence accurate risk assessment and clearance is needed before patients start exercising. The purpose of this review was to evaluate the available literature regarding the risks of exercise for patients with respiratory disease and provide evidence-based recommendations to guide the screening process. A systematic review of 4 databases was performed. The literature was searched to identify adverse events specific to exercise. For COPD, 102 randomized controlled trials that involved an exercise intervention were included (n = 6938). No study directly assessed the risk of exercise, and only 15 commented on exercise-related adverse events. For asthma, 30 studies of mixed methodologies were included (n = 1278). One study directly assessed the risk of exercise, and 15 commented on exercise-related adverse events. No exercise-related fatalities were reported. The majority of adverse events in COPD patients were musculoskeletal or cardiovascular in nature. In asthma patients, exercise-induced bronchoconstriction and (or) asthma symptoms were the primary adverse events. There is no direct evidence regarding the risk of exercise for patients with COPD or asthma. However, based on the available literature, it would appear that with adequate screening and optimal medical therapy, the risk of exercise for these respiratory patients is low.

Physical training for asthma

BACKGROUND

People with asthma may show less tolerance to exercise due to worsening asthma symptoms during exercise or other reasons such as deconditioning as a consequence of inactivity. Some may restrict activities as per medical advice or family influence and this might result in reduced physical fitness. Physical training programs aim to improve physical fitness, neuromuscular coordination and self confidence. Subjectively, many people with asthma report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. Also, as exercise can induce asthma, the safety of exercise programmes needs to be considered.

OBJECTIVES

To gain a better understanding of the effect of physical training on the respiratory and general health of people with asthma, from randomised trials.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials up to January 2013.

SELECTION CRITERIA

We included randomised trials of people over eight years of age with asthma who were randomised to undertake physical training or not. Physical training had to be undertaken for at least 20 minutes, two times a week, over a minimum period of four weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility for inclusion and undertook risk of bias assessment for the included studies.

MAIN RESULTS

Twenty-one studies (772 participants) were included in this review with two additional 2012 studies identified as 'awaiting classification'. Physical training was well tolerated with no adverse effects reported. None of the studies mentioned worsening of asthma symptoms following physical training. Physical training showed marked improvement in cardiopulmonary fitness as measured by a statistically and clinically significant increase in maximum oxygen uptake (mean difference (MD) 4.92 mL/kg/min; 95% confidence interval (CI) 3.98 to 5.87; P < 0.00001; 8 studies on 267 participants); however, no statistically significant effects were observed for forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), minute ventilation at maximal exercise (VEmax) or peak expiratory flow rate (PEFR). Meta-analysis of four studies detected a statistically significant increase in maximum heart rate, and following a sensitivity analysis and removal of two studies significance was maintained (MD 3.67 bpm; 95% CI 0.90 to 3.44; P = 0.01). Although there were insufficient data to pool results due to diverse reporting tools, there was some evidence to suggest that physical training may have positive effects on health-related quality of life, with four of five studies producing a statistically and clinically significant benefit.

AUTHORS' CONCLUSIONS

This review demonstrated that physical training showed significant improvement in maximum oxygen uptake, though no effects were observed in other measures of pulmonary function. Physical training was well tolerated among people with asthma in the included studies and, as such, people with stable asthma should be encouraged to participate in regular exercise training, without fear of symptom exacerbation. More research is needed to understand the mechanisms by which physical activity impacts asthma management.

Effect of physical training on airway inflammation in bronchial asthma: a systematic review

Background

The majority of the global population cannot afford existing asthma pharmacotherapy. Physical training as an airway anti-inflammatory therapy for asthma could potentially be a non-invasive, easily available, affordable, and healthy treatment modality. However, effects of physical training on airway inflammation in asthma are currently inconclusive. The main objective of this review is to summarize the effects of physical training on airway inflammation in asthmatics.

Methods

A peer reviewed search was applied to Medline, Embase, Web of Science, Cochrane, and DARE databases. We included all observational epidemiological research studies and RCTs. Studies evaluating at least one marker of airway inflammation in asthmatics after a period of physical training were selected. Data extraction was performed in a blinded fashion. We decided a priori to avoid pooling of the data in anticipation of heterogeneity of the studies, specifically heterogeneity of airway inflammatory markers studied as outcome measures.

Results

From the initial 2635 studies; 23 studies (16 RCTs and 7 prospective cohort studies) were included. Study sizes were generally small (median sample size = 30). There was a reduction in C-reactive protein, malondialdehyde, nitric oxide, sputum cell counts and IgE in asthmatics with physical training. Mixed results were observed after training for fractional excretion of nitric oxide and bronchial hyperresponsiveness. The data was not pooled owing to significant heterogeneity between studies, and a funnel plot tests for publication bias were not performed because there were less than 10 studies for almost all outcome measures. Physical training intervention type, duration, intensity, frequency, primary outcome measures, methods of assessing outcome measures, and study designs were heterogeneous.

Conclusion

Due to reporting issues, lack of information and heterogeneity there was no definite conclusion; however, some findings suggest physical training may reduce airway inflammation in asthmatics.

Effect of physical training on airway inflammation in animal models of asthma: a systematic review

BACKGROUND

There is little data on the effect of exercise on markers of airway inflammation in human asthmatics. The main objective of this review is to determine the effects of physical training on markers of airway inflammation in animal models of asthma.

METHODS

A peer reviewed search was applied to Medline, Embase, Web of Science, Cochrane, and DARE databases. Data extraction was performed in a blinded fashion.

RESULTS

From the initial 2336 studies, a total of 10 studies were selected for the final analysis. All were randomized controlled trials with low to moderate intensity training on ovalbumin-sensitized mice. In the exercised group of mice, there was a reduction in BAL eosinophils and Th-2 cytokines, no change in Th-1 cytokines, an increase in IL-10, and a reversal of airway remodeling. The data was not pooled owing to significant heterogeneity between studies, and a funnel plot test for publication bias was not performed because there were few studies reporting on any one outcome measure. The asthma models differed between studies in age and gender of mice, as well as in timing of physical training after sensitization. The risk of bias was unclear for some studies though this may not influence outcome measures. The accuracy of data extracted from graphics is unknown.

CONCLUSIONS

Physical training improves airway inflammation in animal asthma models.

Low serum high-density lipoprotein cholesterol in childhood is associated with adolescent asthma

BACKGROUND

Whilst emerging evidence from animal and cell experiments has shown high-density lipoprotein cholesterol to have anti-inflammatory effects consistent with a protective role in asthma, human studies investigating the relationship of high-density lipoprotein cholesterol with asthma have produced conflicting results.

OBJECTIVE

To examine the association between serum lipids among Cypriot children aged 11-12 years and prevalence of asthma at age 15-17 years.

METHODS

In 3982 children, we assessed serum lipids, body mass index and maximal oxygen consumption at baseline (2001-2003) and explored associations with respiratory health at follow-up (2007) using multiple logistic regression models.

RESULTS

Lower levels of high-density lipoprotein cholesterol at age 11-12 years were found in subjects who reported ever asthma (58.2 vs. 60.0 mg/dL, P = 0.005) and active asthma (57.5 vs. 59.9 mg/dL, P = 0.010) in adolescence, in comparison with their respective reference groups. Total cholesterol, low-density lipoprotein and triglycerides had no association with any of the asthma outcomes. In contrast, with estimated odds ratios of 1.89 (95% CI 1.19-3.00) and 1.89 (95% CI 1.02-3.53), ever asthma and active asthma respectively appeared particularly pronounced among those who at baseline had high-density lipoprotein cholesterol <40 mg/dL, even after adjusting for potential confounders including body mass index and maximal oxygen consumption.

CONCLUSIONS & CLINICAL RELEVANCE

Low-serum high-density lipoprotein cholesterol in childhood is associated with an increased risk for asthma in adolescence, suggesting a potential role of this lipoprotein in the pathogenesis of paediatric asthma.

Physical training for asthma

BACKGROUND

People with asthma may show less tolerance to exercise due to worsening asthma symptoms during exercise or other reasons such as deconditioning, as a consequence of inactivity. Some may also restrict activities as per medical advice or family influence and this might result in reduced physical fitness. Physical training programs aim to improve physical fitness, neuromuscular coordination and self confidence. Subjectively, many people with asthma report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. Also, as exercise can induce asthma, the safety of exercise programmes need to be considered.

OBJECTIVES

To gain a better understanding of the effect of physical training on the respiratory and general health of people with asthma, from randomised trials.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials up to April 2011.

SELECTION CRITERIA

We included randomised trials of people over eight years of age with asthma who were randomised to undertake physical training. Physical training had to be undertaken for at least twenty minutes, two times a week, over a minimum period of four weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility for inclusion and the quality of trials.

MAIN RESULTS

Nineteen studies (695 participants) were included in this review. Physical training was well tolerated with no adverse effects reported. None of the studies mentioned worsening of asthma symptoms following physical training. Physical training improved cardiopulmonary fitness as measured by a statistically and clinically significant increase in maximum oxygen uptake (MD 5.57 mL/kg/min; 95% confidence interval (CI) 4.36 to 6.78; six studies on 149 participants) and maximum expiratory ventilation (6.0 L/min, 95% CI 1.57 to 10.43; four studies on 111 participants) with no significant effect on resting lung function (performed in four studies). Although there were insufficient data to pool due to diverse reporting tools, there is some evidence available to suggest that physical training may have positive effects on health-related quality of life, with four of five studies producing a statistically and clinically significant benefit.

AUTHORS' CONCLUSIONS

This review demonstrated that physical training can improve cardiopulmonary fitness and was well tolerated among people with asthma in the included studies. As such, people with stable asthma should be encouraged to partake in regular exercise training, without fear of symptom exacerbation.

Effects of regular exercise on adult asthma

Although many guidelines recommend regular exercise for adults with asthma, the empirical evidence on the effect of exercise on adult asthma has been inconsistent and there are no previous systematic reviews on this topic. To fill in this gap of knowledge, we synthesized the data on the effects of regular exercise on physical fitness, asthma control and quality of life of adult asthmatics. We performed a Medline search from 1980 through June 2011. In the systematic review we included all clinical trials that provided information on the effects of regular exercise on adult asthma. We conducted meta-analyses of maximal oxygen consumption (VO(2)max) and forced expiratory volume in 1 s (FEV(1)) based on 9 studies. A total of 11 studies were included in the analyses, but only 6 of them had a non-exercising reference group of asthmatics. The meta-analyses of randomized controlled trials showed that regular exercise significantly improved VO(2)max. There was no obvious improvement in lung function measurements. Some individual studies showed evidence of improvement in quality of life and asthma control. Meta-analyses provided evidence that regular physical exercise improves physical fitness of adult asthmatics. The results on effects on lung function were inconclusive. There is insufficient evidence to assess the effects of exercise on asthma control and quality of life.

Effects of physical exercise on lung injury and oxidant stress in children with asthma

BACKGROUND

The aim of this study was to investigate the influence of exercise training on oxidative stress and markers of lung inflammation in children with asthma.

METHODS

Thirty children aged 8-13 years diagnosed with asthma were enrolled in the study as well as 13 healthy children. One group received only pharmacological treatment and the other group was also enrolled in an exercise programme. Venous blood and 24-hour urine samples were obtained from the children enrolled in the study at the beginning and end of the study. Leukotriene E4 and creatinine levels were measured in the urine and matrix metallopeptidase (MMP-9), endothelin-1(ET-1), malnodialdehyde (MDA), IgE and specific IgE levels were measured in blood samples.

RESULTS

Leukotriene E4, MDA and MMP9 levels decreased significantly with treatment in both groups (p < 0.001). However, ET-1 levels decreased significant only in the exercise group (26.5 ± 3.6 vs 21.3 ± 2.4 pg/ml respectively, p = 0.001). Moreover, ET-1 levels were found to be significantly lower in the exercise group compared to the only pharmacotherapy group (24.2 ± 3.1 vs 21.3 ± 2.4 pg/ml, p=0.007).

CONCLUSIONS

Positive influences of exercise training in children with asthma may be mediated by decrease in ET-1 levels.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Exercise-Induced Lung Disease: Too Much of a Good Thing?

Exercise in children has important health benefits. However, in elite endurance athletes, there is an increased prevalence of exercise-induced bronchoconstriction and airway inflammation. Particularly at risk are those who practice in cold weather, ice rinks, swimming pools, and air pollution. The inflammation is caused by repetitive episodes of hyperventilation of cold, dry air, allergens, or toxins such as chlorine or air pollution. Children may be particularly at risk for lung injury under these conditions because of the immaturity and ongoing development of their lung. However, studies in pediatric athletes and exercising young children are sparse. Epithelial injury associated with hyperventilation of cold, dry air has not been described in children. However, exercise in the presence of air pollution and chlorine is associated with airway injury and the development of asthma in children; the effect appears to be modulated by both atopy and genetic polymorphisms. While management of exercise-induced bronchoconstriction and asthma is well established, there is little data to guide treatment or prevention of remodeling in athletes or inhalational lung injury in children. Studies underscore the need to maintain high levels of air quality. More investigations should be undertaken to better define the natural history, pathophysiology, and treatment of exercise-induced pulmonary inflammation in both elite athletes and exercising children.

Pulmonary function and abdominal and thoracic kinematic changes following aerobic and inspiratory resistive diaphragmatic breathing training in asthmatics

This study investigated the effect of 8 weeks, three times weekly, of aerobic exercise (AE), diaphragmatic inspiratory resistive breathing (DR), and aerobic exercise combined with diaphragmatic inspiratory resistive breathing (CE) on pulmonary function and abdominal and thoracic dimensions and kinematics in asthmatics. Eighty-eight inactive, moderate-persistent asthmatics were matched and randomly assigned to AE, DR, CE, or nonexercise control (NE) groups (n = 22 each). AE subjects walked and/or jogged at 60% of age-predicted maximum heart rate. DR subjects performed diaphragmatic breathing combined with inspiratory resistive breathing at varying inspiration, expiration ratios. CE subjects utilized a combination of the AE and DR programs. AE, DR, and CE significantly (p ≤ 0.05) improved chest dimensions and kinematics during inspiration at the height of the second intercostal space, during inspiration and expiration at the height of the xiphoid process, and during inspiration and expiration at the height of the midpoint between the xiphoid process and umbilicus. All exercise interventions significantly improved FVC, FEV(1), PEF, and IVC, while MVV improved following AE and CE. However, CE proved superior to AE at improving FVC (p = 0.001), FEV(1) (p = 0.001), and IVC (p = 0.009). There were no significant changes (p > 0.05) in any of the measured parameters in the NE group. CE produces adaptations greater than those for single-mode training in moderate-persistent asthmatics. The results suggest synergy rather than interference between aerobic exercise and diaphragmatic inspiratory resistive breathing and that this mode of training might be useful as an adjunct therapy in asthmatic patients.

The Breathe Easier through Weight Loss Lifestyle (BE WELL) Intervention: a randomized controlled trial

BACKGROUND

Obesity and asthma have reached epidemic proportions in the US. Their concurrent rise over the last 30 years suggests that they may be connected. Numerous observational studies support a temporally-correct, dose-response relationship between body mass index (BMI) and incident asthma. Weight loss, either induced by surgery or caloric restriction, has been reported to improve asthma symptoms and lung function. Due to methodological shortcomings of previous studies, however, well-controlled trials are needed to investigate the efficacy of weight loss strategies to improve asthma control in obese individuals.

METHODS/DESIGN

BE WELL is a 2-arm parallel randomized clinical trial (RCT) of the efficacy of an evidence-based, comprehensive, behavioral weight loss intervention, focusing on diet, physical activity, and behavioral therapy, as adjunct therapy to usual care in the management of asthma in obese adults. Trial participants (n = 324) are patients aged 18 to 70 years who have suboptimally controlled, persistent asthma, BMI between 30.0 and 44.9 kg/m2, and who do not have serious comorbidities (e.g., diabetes, heart disease, stroke). The 12-month weight loss intervention to be studied is based on the principles of the highly successful Diabetes Prevention Program lifestyle intervention. Intervention participants will attend 13 weekly group sessions over a four-month period, followed by two monthly individual sessions, and will then receive individualized counseling primarily by phone, at least bi-monthly, for the remainder of the intervention. Follow-up assessment will occur at six and 12 months. The primary outcome variable is the overall score on the Juniper Asthma Control Questionnaire measured at 12 months. Secondary outcomes include lung function, asthma-specific and general quality of life, asthma medication use, asthma-related and total health care utilization. Potential mediators (e.g., weight loss and change in physical activity level and nutrient intake) and moderators (e.g., socio-demographic characteristics and comorbidities) of the intervention effects also will be examined.

DISCUSSION

This RCT holds considerable potential for illuminating the nature of the obesity-asthma relationship and advancing current guidelines for treating obese adults with asthma, which may lead to reduced morbidity and mortality related to the comorbidity of the two disorders.

TRIAL REGISTRATION

NCT00901095.

Evaluation of Cooper 12-minute walk/run test as a marker of cardiorespiratory fitness in young urban children with persistent asthma

OBJECTIVE

To evaluate Cooper 12-minute run/walk test (CT12) as a one-time estimate of cardiorespiratory fitness and marker of fitness change compared with treadmill fitness testing in young children with persistent asthma.

DESIGN

A cohort of urban children with asthma participated in the asthma and exercise program and a subset completed pre- and postintervention fitness testing.

SETTING

Treadmill fitness testing was conducted by an exercise physiologist in the fitness laboratory at an academic children's hospital. CT12 was conducted in a college recreation center gymnasium.

PARTICIPANTS

Forty-five urban children with persistent asthma aged 7 to 14 years participated in exercise interventions. A subset of 19 children completed pre- and postintervention exercise testing.

INTERVENTIONS

Participants completed a 9-week exercise program where they participated in either swimming or golf 3 days a week for 1 hour. A subset of participants completed fitness testing by 2 methods before and after program completion.

MAIN OUTCOME MEASURES

CT12 results (meters), maximal oxygen consumption ((.)Vo2max) (mL x kg(-1) x min(-1)), and treadmill exercise time (minutes).

RESULTS

CT12 and maximal oxygen consumption were moderately correlated (preintervention: 0.55, P = 0.003; postintervention: 0.48, P = 0.04) as one-time measures of fitness. Correlations of the tests as markers of change over time were poor and nonsignificant.

CONCLUSION

In children with asthma, CT12 is a reasonable one-time estimate of fitness but a poor marker of fitness change over time.

Moderate and vigorous exercise programs in children with asthma: safety, parental satisfaction, and asthma outcomes

BACKGROUND

Previous research suggests that physical activity programs may improve fitness and reduce symptoms in children with asthma, but few studies have included severe asthmatics and focused on safety and parental satisfaction with the programs.

OBJECTIVE

To examine safety, parental satisfaction, and pre- to post-intervention changes in symptoms and quality of life (QOL) in a pilot study of the impact of vigorous physical activity (swimming) and moderate-intensity activity (golf) on inner-city children with asthma.

DESIGN/METHODS

Children with asthma (7-14 years old) residing in Milwaukee's highest asthma prevalence zip codes were randomized to a 9-week swimming or golf program. Pre- and post-intervention data were obtained on safety, parental satisfaction, asthma symptoms, quality of life, and urgent asthma physician visits.

RESULTS

Twenty-eight children in the swimming group and 17 in the golf group completed the program. Combined group analysis (N = 45) revealed that only six symptom exacerbations occurred during 1,125 person-sessions of swimming and golf (all resolved with bronchodilator therapy), 92% of parents were very or extremely satisfied with the program, and post-exercise decreases were observed in asthma symptom severity scores (9.3-7.3, P < 0.001), improved parental QOL (4.9-5.4, P < 0.001), and reduced urgent physician visits for asthma (1.3-0.2 visits per person, P = 0.04). The study lacked sufficient power to perform intergroup comparisons.

CONCLUSIONS

Findings from this pilot study indicate that vigorous (swimming) and moderate-intensity (golf) physical activity programs are well-tolerated, safe, and achieve high parental satisfaction. Participants and parents reported reduced childhood asthma symptoms and physician office visits and improved parental QOL. These findings suggest a potentially beneficial role for moderate to vigorous physical activity in childhood asthma.

Obesity and exercise habits of asthmatic patients

BACKGROUND

National guidelines recommend 20 to 30 minutes of exercise 3 to 5 days a week. However, achieving these goals may be challenging for asthmatic patients whose symptoms are exacerbated by exercise.

OBJECTIVE

To describe relationships among exercise habits, weight, and asthma severity and control in adults with asthma.

METHODS

Self-reported exercise habits were obtained from 258 stable patients by using the Paffenbarger Physical Activity and Exercise Index. Disease status was measured by using the Asthma Control Questionnaire and the Severity of Asthma Scale. Exercise habits were evaluated in multivariate analyses with age, sex, education, body mass index, and asthma control and severity as independent variables.

RESULTS

The mean patient age was 42 years; 75% were women, 62% were college graduates, and 40% were obese. Only 44% of patients did any exercise. In bivariate analysis, patients with well-controlled asthma were more likely to exercise; however, in multivariate analysis, asthma control and severity were not associated, but male sex (P = .01), having more education (P = .04), and not being obese (P < .001) were associated. Asthma control and severity also were not associated with type, duration, or frequency of exercise, but not being obese was associated in multivariate analyses. Only 22% of all patients (49% of those who exercised) met national guidelines for weekly exercise. Not being obese was the only variable associated with meeting guidelines in multivariate analysis (P = .02).

CONCLUSIONS

Compared with the general population, a lower proportion of asthmatic patients did any routine exercise and met national exercise guidelines. Physicians need to manage asthma and obesity to help asthmatic patients meet exercise goals.

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

BACKGROUND

Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

METHODS

The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.

RESULTS

The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.

CONCLUSIONS

There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Evidence for prescribing exercise as therapy in chronic disease

Considerable knowledge has accumulated in recent decades concerning the significance of physical activity in the treatment of a number of diseases, including diseases that do not primarily manifest as disorders of the locomotive apparatus. In this review we present the evidence for prescribing exercise therapy in the treatment of metabolic syndrome-related disorders (insulin resistance, type 2 diabetes, dyslipidemia, hypertension, obesity), heart and pulmonary diseases (chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication), muscle, bone and joint diseases (osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, chronic fatigue syndrome) and cancer, depression, asthma and type 1 diabetes. For each disease, we review the effect of exercise therapy on disease pathogenesis, on symptoms specific to the diagnosis, on physical fitness or strength and on quality of life. The possible mechanisms of action are briefly examined and the principles for prescribing exercise therapy are discussed, focusing on the type and amount of exercise and possible contraindications.

Effects of physical exercise on quality of life, exercise capacity and pulmonary function in children with asthma

OBJECTIVE

To investigate the effects of regular submaximal exercise on quality of life, exercise capacity and pulmonary function in asthmatic children.

PATIENTS AND METHODS

Sixty-two children with mild-moderate asthma (mean age 10.4 (SD 2.1) years) were randomly allocated into exercise and control groups. The exercise group underwent a moderately intensive basketball training program for 8 weeks. A home respiratory exercise program was advised to both groups. Pediatric Asthma Quality of Life Questionnaire (PAQLQ) was used for the evaluation of activity limitation, symptoms and emotional functions. Exercise capacity was evaluated through the physical work capacity (PWC 170 test) on a cycle ergometer and 6-minute walk test. Spirometric tests were also performed and medication and symptom scores were recorded.

RESULTS

Although PAQLQ scores improved in both groups, the improvement in the exercise group was significantly higher. The exercise group performed better in the PWC 170 and 6-minute walk tests, whereas no improvement was detected in the control group at the end of the trial. Medication scores improved in both groups, but symptom scores improved only in the exercise group. No significant changes were detected in pulmonary function in either group, except for peak expiratory flow values in the exercise group.

CONCLUSION

Eight weeks of regular submaximal exercise has beneficial effects on quality of life and exercise capacity in children with asthma. Submaximal basketball training is an effective alternative exercise program for asthmatic children.