# Exercise as it relates to Disease/Do specifically targeted exercise programs improve the symptoms of asthma in children?
## What is the background to this research?

Asthma is a disease characterised by chronic airway inflammation, airway hypersensitivity to various irritants and airway obstruction. It is more common in children than in adults. Airway obstruction may be due to smooth muscle spasms of the bronchi and bronchioles, airway mucosal oedema, increased mucus secretion and/or damage to the airway epithelium.
Allergens are substances that trigger an allergic response. Common allergens that can trigger or aggravate asthma attacks include grass, pollen, animal fur, dust and certain food and drugs. Anxiety, stress, strenuous exercise (exacerbated by cold weather) and respiratory infections are among the most common variables.
The diagnosis of asthma during childhood is approximately 10-15% in the Netherlands; similar figures can be found in other countries within Europe and North America.
Asthma affects about 50-74% to nearly 90% of children, due to physical limitations they tend to avoid physical activity because of symptoms such as shortness of breath, also called exercise induced bronchoconstriction (EIB).

## Where is the research from?

This study was conducted in the Netherlands by professors from various universities who worked in education and social science faculties, university hospitals and the Heideheuvel Asthma Centre.
Given that the prevalence of asthma is higher in children, the chosen study group is very appropriate as it included ages from late childhood to pre-teen (8-13 years). This can influence other researchers to use this information as a foundation for future studies of children from a similar age group and socio economic background.
A few of these same authors worked on other clinical research such as a Home Training Programme for Children with Asthma (1999), Scenario for the Physical Exercise Program for Children with Asthma(1999), Psycho-social and Physiological Effect of Physical Activity with Asthma (1994).

## What kind of research was this?

This research was conducted under a randomised control trial (RCT). Involving 47 children of both genders, who were divided into two groups. A control group (n=24) and experimental group (n=23).
RTC is the most frequently used method to determine the efficacy of new interventions or treatment within a specific demographic. This form of research reduces the risk of bias while providing a precise technique for examining the relationship between an intervention and the outcome.

## What did the research involve?

The intervention trial included forty seven (34 boys and 13 girls) asthmatic children ranging from ages 8 to 13 (mean 10.6). Nine children were recruited from the Heideheuvel Asthma Centre in HIlversum, Netherlands, 19 via a local newspaper advertisement and 20 from a special school [3]l. Only children with a clinical asthma diagnosis were recruited, either suffering from EIB, as defined by a drop of 10% in FEV1 after exercise (as determined by a physician), and/or fear of exercise. The severity of asthma was determined using a questionnaire through the classification of the Dutch Central Advisory Committee for Peer Review (CBO) concerning detection and treatment of asthma in children.
The following physical and psycho-social tests were conducted to ensure a range of thorough and accurate results: maximum incremental exercise test, endurance test, self-perception for children (CBSK), asthma coping test (ACBT), lung function and exercise induced bronchoconstriction test.
To compare data, the children were split into two groups of experimental (n=23) and controlled and control (n=24). The experimental group received physical intervention in groups of 6-10 individuals and the controlled group received no treatment. They were assessed both before and immediately after each intervention.
| Group 1 : Experimental | Group 2: Controlled |
| 23 participants | 24 participants |
| Physical intervention in 6-10 | No extra care or treatment |
Physical Exercise Testing
The physical exercise program lessons consisted of 1 hour of gymnasium based activities. Beginning with a 10 minute warm up, followed by 20 minutes of fitness training (a) and 15–20 minutes of other physical exercises (b). Before and after the exercises, the children were provided explanations and information about asthma and exercise in order to improve their asthma coping behaviour.
Furthermore, twice a week group workouts for one 20-minute activity at home were implemented during a three-month period. Premedication, typically an inhaled ß2-agonist, was administered before training as indicated by the children’s paediatrician, and less frequent wheezing episodes were revealed by inhaling salbutamol.
Lung Function and EIB
Lung function was measured using a pneumotachometer and the exercise induced bronchoconstriction (EIB) was measured on a treadmill. It was hypothesised that there would be no significant changes in the lung function variables and EIB. The results shown below:
| FEV1/FVC | Experimental Group | Control Group |
| Mean | 0.84 | 0.87 |
| SD | 0.07 | 0.08 |
The mean FEV1 /FVC, indicating the degree of obstruction, was in the normal range for both experimental (mean 0.84) and control (mean 0.87) groups.
Psycho-social Indices
A self-perception profile for children was used to measure perceived competence (CBSK). The test consisted of 36 items, each answer was scored between 1 = most competent and 4 = least competent 3.
Asthma coping test (ACBT) for children of 8-13 years was conducted. It consisted of two factors: coping with asthma and it’s consequences daily life (25 questions) and the subjective attitude towards the illness and the amount of anxiety caused by asthma (18 questions). Reliability of the test was acceptable (Cronbach’s alpha was 0.72 and 0.80 for the coping scale and anxiety scale respectively).
However reliable these tests were, they showed no significant improvement on the athletic competence from CBSK test.

## What were the basic results?

Overall, the severity of the asthma may possibly have altered the intervention's effects. The findings revealed that the children in the study had mild to moderate asthma on average. A mean percentage fall at the pretest of 9% in the experimental group and 6% in the control group suggested that these children behaved considerably differently during exercise.
In contrast to the hypothesis, no significant changes were found on perceived physical competence (athletic competence) and self-esteem (global self-worth). This may have been due to the relatively high pretest scores, making average improvement difficult to attain. However, there was a tendency among boys in the experimental group to show a greater increase in athletic competence. Although the metabolic adaptation or efficiency of the cardiopulmonary system did not tangibly improve, the hypothesis suggesting the intervention would have a positive effect on physical condition was substantiated to some degree.
The variation of ways children were recruited for this study exposes potential risk for systematic bias, for example children from a special school for sick children were already in a circumstance which could have influenced their psychosocial state and their peer interaction. There were also no distinguishing differences on the pretest between the experiment and control group.
Furthermore, children in the experiment group had better overall health, were more competent with daily life activities, and had less anxiety about asthma.

## What conclusions can we take from this research?

This study provided a wide variety of evidence based testing for children with exercise induced bronchoconstriction, where a comparison was drawn between two groups to deduce whether an exercise programme would enhance physical performance and psycho-social well being. Gathering all four tests, it can be concluded that using specifically targeted exercise programs improve the symptoms of asthma in children. In light of potential benefits, children with asthma should be encouraged to avoid a sedentary lifestyle and instead engage in ‘life-time’ sports and consistent physical activity. As demonstrated in this study, the enhancement of coping abilities is therefore important to ameliorate the life standard for an asthmatic child.

## Practical Advice

Children with medically controlled asthma may encounter restriction during physical activities, however are encouraged to engage in sports and exercise to enhance their coping abilities. Additionally, seeking a health professional for an asthma action plan is highly recommended and ensuring access to a full inhaler at all times.

## Further Information/Resources

For further information and to educate yourself more about asthmas and its treatments, refer the following links.
* Asthma Treatment - National Asthma Organisation
* Asthma Management
* Sports Medicine Australia
* Anxiety: 9- 18 years
The Helpline 1800ASTHMA, can be used for support, questions or concerns in regards to the chronic disease.

## References

* ↑ Tortora GJ, Derrickson BH. Principles of anatomy and physiology. John Wiley & Sons; 2018 May 15.
* ↑ Smith T. The human body: an illustrated guide to its structure, function, and disorders. Dorling Kindersley; 2000.
* 1 2 3 4 5 6 7 8 9 10 11 12 13 van Veldhoven NH, Vermeer A, Bogaard JM, Hessels MG, Wijnroks L, Colland VT, van Essen-Zandvliet EE. Children with asthma and physical exercise: effects of an exercise programme. Clinical rehabilitation. 2001 Aug;15(4):360-70.
* ↑ Spieth PM, Kubasch AS, Penzlin AI, Illigens BM, Barlinn K, Siepmann T. Randomized controlled trials–a matter of design. Neuropsychiatric disease and treatment. 2016;12:1341.