Exercise as it relates to Disease/The Impact of Self-Directed Exercise in Adults with Partly Controlled Asthma

This Wikibooks page is a fact sheet and analysis of the journal article "Self-Directed Exercise Improves Perceived Measures of Health in Adults with Partly Controlled Asthma" by S Dogra, V Jamnik and J Baker (2010). This analysis has been written as a university assignment for the University of Canberra for the unit: Health, Disease and Exercise.

What is the background to the research?
Asthma is a serious long term respiratory condition that causes great difficulty breathing and can lead to death in some instances. It is caused by hypersensitivity and inflammation of the airways. It is highly prevalent chronic condition that currently affects over 8% of the population in North America. Currently asthma management guidelines indicate particular importance with self-management in the form of a written plan in case of an asthma emergency. Despite the action plan being associated with having better asthma control and fewer emergency care requirements, over 50% of adults have poorly controlled asthma, 28% require urgent care and 35% suffer limitations in day to day activities. Therefore it is important to improve the quality of self-management strategies that are both convenient and sustainable. An alternative that has shown great promise in benefiting the lives of asthma sufferers is exercise especially aerobic exercise. It has been shown to improve asthma control, breathlessness, quality of life and exercise induced asthma symptoms. However this has been shown in medically supervised interventions rather than self-directed exercise programs.

What kind of research was this?
The study had a quasi-experimental design, which means it lacked random assignment. Group assignment was based on the participant’s ability to exercise without interruption during the intervention period. The study also involved the use of both quantitative research (spirometry testing) and qualitative research (questionnaires) to collect information.

What did the research involve?
The research involved recruiting participants from the Greater Toronto Area in Ontario, Canada. Criteria for participation included: The participants were subjected to testing sessions that included measuring their forced expiratory volume in one second (FEV₁) and their forced vital capacity (FVC) using a handheld spirometer. The subjects completed a number of questionnaires to measure asthma control (ACQ), perceived asthma control and quality of life (mini-AQLQ). Finally participants completed a maximal aerobic test on a treadmill. A total of 15 participants were placed in both the Exercise Group and the Control Group.
 * Adults with partly controlled asthma
 * Aged over 18
 * Couldn’t be pregnant
 * Held a current prescription for asthma medication
 * Considered physically inactive according to the Canadian Physical Activity Guidelines (not physically active for 30 minutes at a moderate intensity most days)

Control Group

 * Maintain their current lifestyle for the 12 week period.

Exercise Group

 * Prescribed an individualised unsupervised exercise program. The exercise programs contained 30 minutes of aerobic exercise, upper and lower body strength training and stretching. The programs were altered every 3 weeks to ensure the participants were progressing and giving them the opportunity to provide feedback. The participants were encouraged to exercise 5 days a week for the 12 week period. To track program adherence physical activity logs were used and submitted following the 12 weeks.

What were the basic results?
Due to drop-outs and loss to follow-up only 12 participants from each group were included in the analyses. The results from the program revealed that adherence was very poor. With participants completing approximately 60 minutes of moderate-vigorous aerobic exercise a week. From the group only five participants reported doing any strength-training activities, and of these only three reported doing these exercises at least once per week.

At the beginning of the study there were no baseline differences between the Control and Exercise Group. All participants were taking rescue medications and had similar lung function. After 12 weeks of doing the program there was a significant improvement in perceived asthma control of the Exercise Group compared to the Control Group. However their ACQ score, mini-AQLQ score, aerobic fitness or measures of FEV₁/FVC did not improve. The results did show significant decreases in self-reported asthma symptoms frequency and severity in the Exercise Group compared to the Control Group.

Post-intervention the participants were asked two open-ended questions:
 * 1) Briefly explain the impact that adopting an exercise program has had on you.
 * 2) Do you believe that regular exercise has led to a change in your asthma? In what way?

When looking at the answers three common themes emerged physical fitness, asthma management and well-being. With regards to physical fitness participants indicated an increase in ability to perform daily tasks, for example walking upstairs and not running out of breath. The participants noted improvements in their self-belief and confidence to exercise. Improved mental health was reported and the participants found themselves worrying less about having an asthma attack. One participant indicated that they didn’t enjoy the program or exercising in general, whilst everyone else specified at least two advantages to the exercise program.

What conclusions can we take from this research?
The aim of the study was to determine whether self-directed exercise leads to positive changes in both perceived and measured health outcomes in adults with partly controlled asthma. The results did show improvement in perceived asthma control, subjective measures such as asthma symptomology, perceived fitness and well-being, however didn’t lead to any changes in objective measures. Adherence to the program was poor especially when it came to the strength training component. This is the first study to look at the impact of self-directed exercise program in adults with asthma, although there was study that did look at a similar program in children. The study showed similar results in regards to poor compliance. Other research using unsupervised exercise programs in different clinical populations found that although there are psychological benefits to unsupervised exercise, it doesn’t impact on clinical measures. Although there weren’t many improvements seen in the objective measures this shouldn’t take away from the fact that majority of the participants in the Exercise Group self-reported perceived improvements even though they didn’t totally adhere to the program. Therefore this may indicate that by simply incorporating a small amount of physical activity to a sedentary lifestyle subtle improvements can be made to improve quality of day to day life in someone who is suffering from asthma.

The results from the study should be taken lightly due to the following limitations:
 * Small sample size
 * Subtle changes in submaximal aerobic fitness markers such as heart rate were not observed after the 12 weeks
 * The study was reliant on a self-reporting method
 * Self-belief was not measured at baseline or follow-up therefore it is not known if it contributed to low adherence
 * Limited amount of qualitative data

Future research should look at including different forms of exercise into the unsupervised program instead of just aerobic and strength training. The research should consider doing a similar study but including a supervised exercise group as well.

Practical Advice
The research showed that even by completing a small amount of exercise per week at a low intensity the subjects experienced perceived improvements in asthma control. Therefore I would highly recommend for any adults who currently have partly controlled asthma to participate in aerobic exercise.

Further Information/Resources

 * Asthma Australia http://www.asthmaaustralia.org.au/
 * Australian Asthma Handbook http://www.asthmahandbook.org.au/clinical-issues/exercise/physical-activity
 * American Academy of Allergy Asthma and Immunology https://www.aaaai.org/conditions-and-treatments/library/asthma-library/exercise-and-asthma
 * Journal Article: The effect of a home exercise programme in children with cystic fibrosis and asthma, Holzer Fj. Schnall R. Landau LI.