Eur J Epidemiol (2012) 27:397–407
DOI 10.1007/s10654-012-9684-8
REVIEW
Effects of regular exercise on adult asthma
Sirpa A. M. Heikkinen • Reginald Quansah •
Jouni J. K. Jaakkola • Maritta S. Jaakkola
Received: 22 August 2011 / Accepted: 2 April 2012 / Published online: 25 April 2012
Ó Springer Science+Business Media B.V. 2012
Abstract 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 per-
formed 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 (VO2max) and forced expiratory
volume in 1 s (FEV1) 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 VO2max. There
was no obvious improvement in lung function measure-
ments. 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
S. A. M. Heikkinen
R. Quansah
J. J. K. Jaakkola (&)

M. S. Jaakkola
Center for Environmental and Respiratory Health Research,
University of Oulu, POB 5000 (Aapistie 1), 90014 Oulu, Finland
e-mail: jouni.jaakkola@oulu.fi
S. A. M. Heikkinen
M. S. Jaakkola
Respiratory Medicine Unit, Institute of Clinical Medicine,
University of Oulu and Oulu University Hospital, Oulu, Finland
J. J. K. Jaakkola
Institute of Health Sciences, University of Oulu, Oulu, Finland
insufficient evidence to assess the effects of exercise on
asthma control and quality of life.
Keywords Asthma
Exercise
Lung function
Maximal
oxygen consumption
Meta-analysis
Systematic review
Introduction
Asthma is among the most common chronic diseases in the
working-aged populations. Asthma-related health problems
have considerable contribution to reduced quality of life,
disability and increased health-care costs [1]. Improvement
in asthma management would have substantial public
health benefits. Although many guidelines recommend
regular exercise for adults with asthma, the empirical evi-
dence on the effect of exercise on adult asthma has been
inconsistent and there are no previous systematic reviews
on this topic.
Asthma patients often limit physical exercise to avoid
respiratory symptoms, and preliminary evidence indicates
that there is a self-imposed decrease in physical activity
among asthmatics, even among those with mild asthma,
and patients with asthma seem to have lower physical
fitness than their peers [2]. This may predispose asthma
patients to severe long-term health risks and impair the
prognosis of asthma. Exercise-induced asthma has caused
fear for breathlessness and asthma attacks, and the lack of
proper exercise guidelines often limits asthma patients
from taking part in physical activity. However, exercise-
induced bronchoconstriction can be prevented or reduced
by pretreatment with short-acting bronchodilator medica-
tion and with a 10–15-min warm-up [3].
In some longitudinal studies, regular physical activity
has been associated with reduced risk of asthma
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398 S. A. M. Heikkinen et al.

exacerbations [4] and attenuation of lung function decline inflammatory disease, which influenced the diagnostic
among asthmatics [5]. However, there has been limited and treatment practices),
evidence on the effects of physical training on asthma (b) was an original study,
control and prognosis in adults from clinical trials. (c) was a clinical trial,
To fill in this gap of knowledge, we summarized the (d) included adult population (16–65 years) of
available evidence of the effects of regular physical exer- asthmatics,
cise on physical fitness, asthma control and quality of life (e) provided sufficient information that could be used to
in adult asthma. We conducted a systematic review and estimate the relation between regular physical exer-
meta-analysis of clinical trials on the effects of regular cise and asthma control or physical fitness or quality
exercise on the health of adult asthmatics. The meta-anal- of life, and
yses focused on maximal oxygen consumption (VO2max) (f) was published in a peer-reviewed journal in any of the
and forced expiratory volume in 1 s (FEV1). The remaining following languages: English, Finnish, French, Ger-
outcomes were synthesized qualitatively as it was not man, Spanish and Swedish.
meaningful to perform meta-analysis because heteroge-
A study was excluded if the authors reported data on
neous outcome measures had been used for asthma control
asthma patients in general but opted not to examine the
and quality of life.
data on adult patients separately. For any study to be
included in our analysis its outcome and exposure defini-
tions had to be compatible with ours.
Methods

Search strategy, and inclusion and exclusion criteria

We performed a systematic literature search of the Ovid
Medline (28.6.2011) database from 1980 through June
2011 using the search strategy described in Fig. 1a, b. The
studies were screened for their eligibility using the
following inclusion criteria: The study
(a) was published after 1st of January 1980 (correspond-
ing to the period when asthma was recognized as an
Studied intervention and outcomes
The studied intervention was regular physical activity or a
physical training programme offered by the investiga-
tor(s) for the purposes of studying its effects on asthma.
The outcomes of interest included physical fitness, asthma
control and quality of life. The definition of asthma had to
be based on a diagnosis following published guidelines or
regular use of asthma medication.

(a) MeSH term asthma

MeSH dance therapy MeSH exercise MeSH exercise therapy MeSH locomotion MeSH physical education and training MeSH physical training

(b) asthma

AND

Abstract or title (ab. ti.) Title (ti.)

aerobic exercise* aerobic train* exercis*

circuit train* cycling

endurance train* fitness

kinesitherap* musc* training

physical exercise* physical train*

running walking

Fig. 1 a Medline search strategy using Medical Subject Headings (MeSH). All subheadings under the MeSH terms were included. b Medline
search strategy using text search words

123
Effects of regular exercise on adult asthma
Quality assessment
We assessed the quality of the studies using the following
items: description of drop-outs, description of the method of
randomization, similarity of the comparison groups at
baseline, description of the eligibility criteria, and an inten-
tion-to-treat analysis, applying the instructions by Jadad
et al. [6] and the Delphi list [7], but taking into account that
these have been developed mainly for randomized controlled
trials. Randomized controlled trials are considered here as
the best quality studies because of their strong study design.
Data extraction
The characteristics and results of each article included were
recorded in a data collection form by two authors inde-
pendently (SH, RQ). After this, the forms were compared
and any differences discussed. The characteristics of
interest were study design, study population, exercise
intervention, definition and severity of asthma, assessment
of asthma control, assessment of physical fitness, assess-
ment of quality of life, quantitative and qualitative results,
possible subgroup analyses, and the quality of the study.
Statistical analysis
The eligible studies rarely provided data on the mean intra-
individual difference and variance for the changes in FEV1
and VO2max. The mean difference and its corresponding
variance were computed in excel using standard methods
[8–10]. When there was evidence of substantial heteroge-
neity (i.e. I2 [ 50 %) [11], separate meta-analyses were
performed for the randomized controlled trials (RCTs) and
the non-randomized controlled or uncontrolled trials (called
here non-RCTs). Else the effect estimates from the trials
were pooled together. The fixed effect model was used to
calculate the summary weighted mean difference (WMD)
and 95 % confidence interval (95 % CI). Dogra et al. [12]
applied a measure for VO2max which was different from all
the other studies, so the Hedges’ g was used to compute the
weighted standardized mean difference (SMD) and 95 % CI
to achieve corresponding scale of measures [8]. The small
number of studies limited the possibility for formal evalua-
tion of publication bias and potential sources of heteroge-
neity. Meta-analyses were performed using STATA 11.
Results
Results of the systematic literature search
The Medline search identified a total of 1,152 articles, of
which 1,132 articles were excluded for being irrelevant by
399
title or abstract. The full text of the remaining 20 articles
was reviewed in detail. After the evaluation, 11 articles
fulfilled our inclusion criteria and were included in the
more detailed analysis. Reasons for exclusion were: study
population included only children \1 years, only one
exercise session was performed, only patients with chronic
obstructive pulmonary disease (COPD) were examined, the
intervention included only breathing exercises or stretch-
ing, or they were not clinical trials. Bundgaard et al. [13,
14] were on the same trial and we included the more recent
one. The reference lists of the articles that fulfilled the
inclusion criteria were also reviewed, but no new relevant
references were found. The systematic review was thus
based on the 11 studies, of which 9 were suitable for the
meta-analysis (Tables 1, 2). The remaining 2 studies were
analyzed qualitatively since they did not present quantita-
tive data that could be included in the meta-analyses.
Characteristics of the studies included
Four studies were RCTs and 7 were non-RCTs. Of the non-
RCTs, one study [12] had an appropriate reference group
but the study was non-randomized, and it was considered
as non-RCT from the perspective of our aims. The ran-
domized controlled trials included either a non-exercising
reference group of asthmatics or had a low level exercise
group as in the study of Bundgaard et al. [13]. The
remaining studies did not include any reference group or
had a reference group of non-asthmatics. Therefore those
studies did not provide a comparison on whether regular
exercise has effects on asthma and were considered as non-
controlled in this context.
The studies usually provided sparse background data. In
8 studies, the majority of the participants were females [12,
15–21], and in one study all of the participants were
females [22]. None of the studies provided information on
ethnicity of the subjects. Only Arandelovic et al. [23] and
Hallstrand et al. [22] reported the atopic status of the study
participants and in these the proportion of atopics was over
60 % in all groups. Dogra et al. [12] and Mendes et al. [19]
reported body mass index (BMI) of the study participants
and in both studies average BMI was similar in both
comparison groups. Cochrane and Clark [15] included only
never smokers and Dogra et al. [12] and Arandelovic et al.
[23] included never smokers and ex-smokers, while this
information was not available for other studies. The
severity of asthma of the participants varied from mild to
severe and this information is shown for each study in
Tables 1 and 2.
The duration of the training programme varied from
5 weeks to 2 years (Tables 1, 2). The recommended fre-
quency was usually 1–3 times a week. The target intensity
ranged from 60 to 90 % of the maximal heart rate, but this
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Table 1 Characteristics of the randomized controlled trials (RCTs) included in the systematic review and meta-analysis
Author, country Participants Intervention programme Outcome used Results on outcomes: mean ± SD
in the meta-
analyses Exercise group Reference group
Initial Final Initial Final

Mendes et al. [19], 89 moderate to severe asthmatics; Aerobic exercise for 30 min per FEV1 2.3 (1.3–3.2)a 2.3 (1.0–3.4)a 2.3 (1.4–3.19)a 2.4 (1.4–3.4)a
Brazil 44 in intervention group and 45 session, twice a week for
in reference group 3 months
Arandelovic et al. 65 mild persistent asthmatics; 45 Indoor swimming for 1 h per FEV1 3.55 ± 0.85 3.65 ± 0.86 3.29 ± 0.78 3.33 ± 0.84
[23], Serbia subjects in intervention group session, twice a week for
and 20 in reference group 6 months
Cochrane and Clark 36 moderate to severe asthmatics; Indoor aerobic exercise for 30 min VO2max 23.0 ± 4.7 28.4 ± 6.0 25.9 ± 6.7 25.0 ± 5.9
[15], England 18 subjects in intervention group per session including aerobics, FEV1 2.58 ± 0.68 2.97 ± 0.69 2.94 ± 0.67 3.13 ± 0.80
and 18 in reference group cycling and jogging, and
muscular exercises, 3 times a
week for 3 months
Bundgaard et al. 27 asthmatics; 16 subjects in Indoor aerobic exercise for 1 h per VO2max 27.6 30.4 (p = 0.02)b 28.2 27.7 (p = 0.33)b
[13], Denmark intervention group and 11 in session including running,
reference group jumping and muscular exercises,
twice a week for 2 months
Data are presented as mean ± SD unless otherwise stated
FEV1 forced expiratory volume in 1 s, VO2max maximal oxygen consumption
a
Findings reported as mean values and their 95 % confidence interval (95 % CI)
b
p values were used to calculate the 95 % CIs
S. A. M. Heikkinen et al.
 Table 2 Characteristics of the non-randomized controlled and uncontrolled trials (non-RCTs) included in the systematic review and meta-analysis
Author, country Participants Intervention programme Outcome used in Results on outcomes: mean ± SD
the meta-analyses
Exercise group Reference group
Initial Final Initial Final
Effects of regular exercise on adult asthma

Dogra et al. [12], 36 asthmatics; 18 subjects in Individualized aerobic exercise, 3 VO2max 2.63 (0.20)a 2.88 (0.21)a 2.66 (0.27)a 2.77 (0.29)a
Canada intervention group and 12 in times a week for 12 weeks
reference group
Hallstrand et al. [22], 5 mild asthmatics Step aerobics, 3 times a week for VO2max 22.73 ± 4.68 25.29 ± 4.70
USA 10 weeks FEV1 3.10 ± 0.22 3.12 ± 0.30
Meyer et al. [20], 31 mild to severe asthmatics Circuit and endurance training for – NA NA NA NA
Germany 1 h per week for 2 years
Emtner et al. [16], 26 mild to moderate asthmatics Indoor swimming for 45 min per FEV1 2.2 ± 0.8 2.5 ± 0.7
Sweden session, at least twice a week for
10 weeks
Robinson et al. [21], 8 moderate to severe asthmatics Aerobic exercise including VO2max 27.5 (21.9–33.0)b 31.3 (23.5–39.1)b
New Zealand running and jumping, and
muscular exercises, at least 3
sessions per week for 12 weeks
Girodo et al. [18], 67 asthmatics, 44 subjects in Aerobic training for 1 h, 3 times a – NA NA NA NA
Canada intervention and 23 in week for 16 weeks
reference group
Freeman et al. [17], 9 mild to moderate asthmatics Running on a motorized treadmill, VO2max 41.0 ± 8.2 43.8 ± 8.8
England 3 times a week for 5 weeks FEV1 3.24 ± 0.74 3.16 ± 0.83
Data are presented as mean ± SD unless otherwise stated
FEV1 forced expiratory volume in 1 s, VO2max maximal oxygen consumption, NA non-applicable: these studies did not present data on VO2max or FEV1
a
Findings reported as mean (SE)
b
Findings reported as mean values and their 95 % confidence interval (95 % CI)
401

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402
information was not available for 6 studies. The exercise
programmes included running, cycling, aerobics, jogging,
badminton, jumping, callisthenics, swimming and/or pool-
exercises. Muscular exercises were also included in some
of the training programmes, including leg, arm, back and
trunk exercises. Three studies included also educational
sessions on asthma [15–17].
Girodo et al. [18] presented two intervention groups: one
with physical training and one with physical training and
breathing exercises combined. The latter group increased
their physical activity more than the group with mere phys-
ical training. As we could not know whether the effects in this
study resulted from regular exercise or breathing exercises,
we did not include the study in the analyses.
The definitions of asthma were based on the Global
Initiative for Asthma [12, 19, 23, 24], the National Asthma
Education and Prevention Program (USA) [22, 25], the
International Consensus Report of Asthma (Germany) [20,
26] or the Thoracic Society of Australia and New Zealand
Definition [21, 27]. Other studies based their diagnosis on
the use of asthma medication [13, 15, 16] and in two
studies the definition remained unclear [14–18].
Outcome assessment
VO2max was assessed as the measure of physical fitness by
maximal exercising in a bicycle ergometer or a treadmill
test. FEV1 was assessed by spirometry or a body
plethysmograph.
In seven studies, [12, 15, 16, 18, 19, 21, 22] patients
were asked to keep diaries for the assessment of asthma
control. Four studies used questionnaires designed specif-
ically for the study. Studied items included asthma symp-
toms such as wheeze, cough, breathlessness on exertion
and nocturnal waking, use of bronchodilator medication,
ability to work and to carry out physical training, asthma-
symptom-free days and peak expiratory flow (PEF). In one
study, asthma control was assessed using the Asthma
Control Questionnaire [12, 28]. Two studies [19, 20] kept
records of emergency department visits and hospitaliza-
tions due to asthma among the subjects.
Questionnaires were used for assessing the quality of
life, including the mini- Asthma Quality of Life Ques-
tionnaire [12, 29] and the asthma-specific Health Related
Quality of Life questionnaire [19, 30].
Effect of regular exercise on maximal oxygen uptake
(VO2max)
Two RCTs, one non-randomized controlled trial and three
uncontrolled trials studied the impact of regular exercise on
VO2max (Tables 1, 2). In our preliminary meta-analysis of
all 6 studies, evidence of substantial heterogeneity was
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S. A. M. Heikkinen et al.
noted. For this reason the meta-analysis was conducted
separately for the RCTs and the non-RCTs. Figure 2a is a
forest plot for the RCTs showing also the summary esti-
mate. The forest plot and the summary estimate for the
non-RCTs are shown in Fig. 2b.
Compared to the referents, the exercise group showed a
significant improvement in VO2max [Fixed effect model-
weighted mean difference (WMD): 3.66, 95 % CI:
3.44–3.88] in the RCTs. There was evidence of substantial
heterogeneity in the study-specific effect estimates
(I2 = 98.7 %, p = 0.00, Q-statistics = 76.11), although
both RCTs showed a significant positive effect (Fig. 2a). In
contrast, in the non-RCTs no significant improvement in
VO2max was detected (Fig. 2b).
Effect of regular exercise on FEV1
The effect of regular exercise on FEV1 was studied in 3
RCTs and 3 non-RCTs (Tables 1, 2). The forest plot and
the summary estimate for the RCTs are shown in Fig. 3a.
The results of the meta-analysis showed a slight improve-
ment in FEV1 in response to the intervention, but chance
could not be excluded because the confidence interval
included 0 (Fig. 3a). Performing meta-analysis on the 3
non-RCTs gave similar results (Fig. 3b). Consistent results
were observed when the analysis was carried out on all 6
studies (WMD: 0.09, 95 % CI: -0.11–0.29, I2 = 0.0 %,
p = 0.923, Q-statistics = 1.81) (Fig. 3c).
Effect of regular exercise on asthma control and quality
of life
Many different measures were used to assess asthma con-
trol and quality of life. Consequently, there was insufficient
information on these outcomes to compute a meaningful
summary in meta-analysis.
In the study by Bundgaard et al. [13], the PEF
improved in the intervention group from an average of
383–420 l/min and decreased in the reference group from
an average of 403–396 l/min, but the result was not sta-
tistically significant. In the study by Robinson et al. [21],
there was a small but significant increase in PEF after the
training period, but this study did not include any reference
group of non-asthmatics.
The study by Bundgaard et al. [13] showed a significant
decrease in the use of short-acting beta2-agonist medication
from an average of 4.91 puffs/day during the first week of
training to an average of 3.41 puffs/day (p = 0.037) during
the last week of training among the intervention group. In
the reference group, the use of this medication increased
from an average of 3.41 before to an average of 7.08 after
the study period (p = 0.14). In the study by Mendes et al.
[19], there was a significant increase in the number of days
Effects of regular exercise on adult asthma 403

(a) Effect of regular exercise on

Study VO2 max mL/ min/kg %

ID WMD (95% CI) Weight

Cochrane and Clark, 1990 6.30 (5.67, 6.93) 11.98

Bundgaard et al 1983 3.30 (3.07, 3.53) 88.02

Overall (I-squared = 98.7%, p = 0.000) 3.66 (3.44, 3.88) 100.00

-10 -5 -2.5 0 2.5 5 10

(b) Effect of regular exercise on

Study VO2 max mL/ min/kg %

ID SMD (95% CI) Weight

Hallstrand et al 1999 0.49 (-0.78, 1.76) 11.12

Dogra et al 2011 0.14 (-0.59, 0.87) 33.54

Robinson et al 1992 0.27 (-0.45, 0.99) 34.65

Freeman et al 1989 0.31 (-0.62, 1.24) 20.69

Overall (I-squared = 0.0%, p = 0.969) 0.26 (-0.16, 0.68) 100.00

-10 -5 -2.5 0 2.5 5 10

Fig. 2 a The mean difference (WMD) and the 95 % confidence
interval (95 % CI) for the effect of regular exercise on maximal
oxygen consumption (VO2max) in ml/min/kg in randomized con-
trolled trials; 95 % CI of the summary weighted mean difference does
not include 0, suggesting a significant improvement related to the
intervention. b The standardized mean difference (SMD) and 95 % CI
for the effect of regular exercise on VO2max in ml/min/kg in non-
randomized controlled trials. 95 % CI of the overall summary
standardized mean difference does include 0, suggesting a non-
significant effect of the intervention. The boxes represent effect
estimate of each study based on variance; the horizontal line
represents weighted mean difference with 95 % CI; the solid vertical
line represents no effect; effect estimate on the left hand side of the
solid vertical line denotes a non-favorable effect; effect estimate on
the right hand side of the solid vertical line denotes a non-favorable
effect of the intervention

without asthma symptoms after 30 days of training
(p \ 0.001), while in the reference group statistically sig-
nificant improvement was not observed.
In the study by Meyer et al. [20], 9 patients had been
hospitalized for asthma in the 2 years prior to the study for
a total of 218 in-hospital days. During the 2 years of the
study period, in-hospital days decreased to 29 days
(p \ 0.001). A reference group of 10 patients had been
hospitalized for asthma in the 2 years prior to the study for
a total of 236 in-hospital days and this decreased during the
2-year study period only slightly to 201 in-hospital days
(p \ 0.2). The study by Emtner et al. [16] showed a
decrease in the total number of emergency department
visits from 9 to 3 after the training period, but this study did
not have a non-exercising reference group of asthmatics.
Dogra et al. [12] showed that the Asthma Control
Questionnaire score (excluding spirometry) and mini-
AQLQ score significantly improved in the intervention
group compared to the reference group. Mendes et al. [19]
detected a decrease in physical limitation and symptom
frequency, and improvement in psychosocial domain
measured with HRQoL-questionnaire in the intervention

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404 S. A. M. Heikkinen et al.

(a) Effect of regular exercise on

Study FEV1 %

ID WMD (95% CI) Weight

Arandelovic et al 2007 -0.06 (-0.55, 0.43) 49.11

Cochrane and Clark 1990 0.20 (-0.31, 0.71) 45.41

Mendes et al 2010 0.10 (-1.36, 1.56) 5.48

Overall (I-squared = 0.0%, p = 0.768) 0.07 (-0.27, 0.41) 100.00

-1.5 -1 -.5 0 .5 1 1.5

Effect of regular exercise on

(b) FEV1
Study %

ID WMD (95% CI) Weight

Hallstrand et al 1999 0.02 (-0.31, 0.35) 57.39

Emtner et al 1996 0.30 (-0.13, 0.73) 33.14

Freeman et al 1989 -0.08 (-0.88, 0.72) 9.47

Overall (I-squared = 0.0%, p = 0.533) 0.10 (-0.14, 0.35) 100.00

-1.5 -1 -.5 0 .5 1 1.5

Effect of regular exercise on

(c)
Study FEV1 %

ID WMD (95% CI) Weight

Arandelovic et al 2007 -0.06 (-0.55, 0.43) 16.88

Cochrane and Clark 1990 0.20 (-0.31, 0.71) 15.61

Hallstrand et al 1999 0.02 (-0.31, 0.35) 37.67

Emtner et al 1996 0.30 (-0.13, 0.73) 21.75

Mendes et al 2010 0.10 (-1.36, 1.56) 1.88

Freeman et al 1989 -0.08 (-0.88, 0.72) 6.21

Overall (I-squared = 0.0%, p = 0.874) 0.09 (-0.11, 0.29) 100.00

-1.5 -1 -.5 0 .5 1 1.5

123
 Effects of regular exercise on adult asthma
b Fig. 3 a The mean difference (WMD) and the 95 % confidence
interval (95 % CI) for the effect of regular exercise on forced
expiratory volume in 1 s (FEV1) in randomized controlled trials; 95 %
CI of the summary weighted mean difference does include 0,
suggesting a non-significant effect of the intervention. b The weighted
mean difference (WMD) and 95 % CI for the effect of regular
exercise on FEV1 in non-randomized controlled trials. 95 % CI of the
overall summary weighted mean difference does include 0, suggest-
ing a non-significant effect of the intervention. c The weighted mean
difference (WMD) and 95 % CI for the effect of regular exercise on
FEV1 in all 6 studies (3 randomized controlled and 3 non-randomized
controlled trials). 95 % CI of the overall summary weighted mean
difference does include 0, suggesting a non-significant effect of the
intervention. The boxes represent effect estimate of each study based
on variance; the horizontal line represents weighted mean difference
with 95 % CI; the solid vertical line represents no effect; effect
estimate on the left hand side of the solid vertical line denotes a non-
favorable effect; effect estimate on the right hand side of the solid
vertical line denotes a non-favorable effect of the intervention
group (p \ 0.001), while no significant improvement was
observed in the reference group.
Discussion
Asthma severity and hospitalizations for asthma have
increased over the past four decades and it has been sug-
gested that decreased physical activity is a contributor to
the poor asthma control [31]. Some previous studies have
suggested that adult asthmatics could benefit from physical
exercise, but these studies have been inconsistent and have
not been reviewed systematically earlier. We conducted a
systematic review and meta-analysis to address whether
physical exercise brings health benefits to adult asthmatics.
Eleven studies were identified in our systematic search, 9
of which were eligible for meta-analysis. The results of the
meta-analysis based on RCTs show that asthmatics benefit
from physical exercise by increasing VO2max signifi-
cantly, the effect estimate being 3.66 ml/min/kg (95 % CI
3.44–3.88). We were not able to find any meta-analysis on
the effect of regular physical exercise on VO2max in
healthy adults, but a recently published controlled inter-
vention study showed a significant improvement in
VO2max after 8 weeks of daily cycling, the effect estimate
being 2.6 ml/min/kg (p \ 0.003) [32]. Thus, the effect was
slightly smaller among healthy adults compared to that
detected among asthmatics in our meta-analysis. The
results of our systematic review and meta-analysis show
that adult asthmatics can exercise and improve their
physical fitness in the same way as the healthy ones. A
small increase in FEV1 after the training period was
detected in our meta-analysis, the effect estimate being
0.09 l/s, but chance could not be excluded, as the confi-
dence interval included 0, so this finding was inconclusive.
Some cross-sectional studies have suggested that regular
405
physical activity is associated with a higher level of FEV1
[33] among healthy subjects, but no meta-analysis of
intervention studies on the effect of regular exercise on
lung function could be found. Based on qualitative evalu-
ation of individual studies, there was some evidence that
physical exercise may lead to improvement in quality of
life and asthma control, including reduction in the use of
short-acting bronchodilating medication and improvement
in PEF.
Validity of results
This systematic review and meta-analysis has a number of
strengths. First, the guidelines for conducting and reporting
systematic reviews proposed by the Consolidated Standards
of Reporting Trials (CONSORT) statement [34] and the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement [35] were applied.
Second, all published studies on the subject were retrieved by
applying a comprehensive logical search strategy to reduce
selection bias. Third, the eligibility criteria for inclusion of
the relevant published studies were pre-specified.
However, there are some limitations to this review. The
number of studies identified in the systematic review was
small and therefore it was not possible to investigate
sources of observed heterogeneity between the study-spe-
cific effect estimates. The original studies were in general
small and thus, under-powering of the meta-analysis may
be a problem. Because of the small number of the studies
for each outcome and type of study design, we could not
make interpretations related to potential publication bias
based on a funnel plot. Language bias could be critical in
general, but our systematic review included studies pub-
lished in 6 different languages including English, French,
Finnish, German, Spanish and Swedish. Thus, language
bias is not a likely explanation for our findings. Bias in the
selection of the original studies is very unlikely in this
review because the eligibility criteria were pre-defined and
independent of the findings of the studies.
Only a few of the original studies were randomized
controlled trials and none of these studies described the
randomization process. The purpose of randomization is to
minimize selection bias and confounding by ensuring that
both the intervention and the reference groups are balanced
in unknown and known determinants of the outcomes.
Improper randomization could bias the results of the ori-
ginal studies. Some studies included in the meta-analysis
were uncontrolled and therefore, selection bias from the
allocation of the participants into the intervention could not
be excluded in them. Withdrawals were mentioned in 7
studies [13, 16–19, 21, 22], but the participants who
dropped out of the intervention were not included in the
final analysis. Future studies should adopt both analysis-
123
406
by-approach and intention-to-treat approach to analyze
their data.
Synthesis of the findings with previous studies
Our systematic search of the scientific literature did not
identify any previous systematic review with a meta-anal-
ysis that has reported on the effects of physical exercise in
adult asthma. Ram et al. [36] reported a systematic review
and meta-analysis on exercise and asthma focusing on
children. They included only RCTs and only 2 of the
studies were on adults, and no results were presented
separately for adults. Furthermore, we recognized that both
RCTs and non-RCTs may help to answer the question if
physical exercise is of any benefit to adult asthmatics. Our
search was restricted to studies published after January 1st
1980, because after this period asthma was recognized as
an inflammatory disease and this influenced diagnostic and
treatment practices.
Ram et al. [36] did not find any effect of physical
exercise on resting lung function based on studies con-
ducted predominantly in children, but noted that physical
exercise leads to improvement in cardiopulmonary fitness
as measured by an increase in maximal oxygen consump-
tion. Our findings focusing on adult asthmatics were con-
sistent with these findings reported previously in children.
The strength of the average intervention effect on
VO2max and FEV1 in our meta-analyses was smaller than
those reported for children. The reason for this may be that
VO2max and FEV1 after intervention are functions of fit-
ness level before the intervention, age and type of physical
training regime. Adult asthma patients may have had a
lower fitness level compared to the children reported in the
previous studies. In addition, we were less restrictive
concerning the level of exercise and physical activity
reported and these varied widely with respect to frequency,
intensity and duration in the studies included in this review.
Our study fills in an important gap in current knowledge
showing that physical exercise improves physical fitness in
adult asthmatics. The findings on lung function level
remain inconclusive. Thus, regular exercise may have
potential for improving the health and disease control of
asthmatic adults. The vast majority of the study partici-
pants in the present systematic review and meta-analysis
were female adult asthmatics, so our findings should be
interpreted with caution in male asthmatics.
Some studies have suggested that exercise may have
short-term beneficial effects on airway smooth muscle [31].
American College of Sports Medicine states that although
exercise may be a trigger for asthmatic airflow obstruction
for some people, research indicates that it is possible to
build up tolerance to physical activity over time [37]. The
mechanisms underlying observed long-term improvement
123
S. A. M. Heikkinen et al.
in VO2max or potential improvement in asthma control as
response to regular physical exercise among asthmatics are
currently not well known. Beneficial effects on breathing
pattern and reduction in bronchial hyperresponsiveness
have been suggested as potential mechanisms [4, 31]. Our
research group suggests that improved oxygen uptake
capacity accompanied by increased threshold for getting
breathlessness will ensure that those with asthma can cope
with their everyday life at a lower effort level, thus giving a
better effort-benefit ratio and leaving more breathing
reserves. In addition, a very recent report suggested that a
3-month period of aerobic training led to significant
decreases in markers of airway inflammation, including
induced sputum eosinophil cell counts and fractional
exhaled nitrogen oxide [38].
Conclusions
This systematic review and meta-analysis provides evi-
dence that regular physical exercise improves significantly
physical fitness measured as maximal oxygen consumption
in adult asthmatics. The results on lung function remain
inconclusive. There is some evidence of improvement in
asthma control and quality of life based on qualitative
evaluation of the evidence.
There is a need for large and well-designed randomized-
controlled trials to investigate further potential benefits that
regular exercise may have on asthma to be able to give
more specific recommendations concerning exercise as part
of treatment of adult asthmatics. The need for complete
reporting in future studies is also crucial for quantitative
synthesis of results. Asthmatics may also benefit from
future studies focusing on both the efficacy (the analysis-to
protocol approach) and the effectiveness (the intention-to-
treat approach) of interventions.
Acknowledgments Librarian Raija Heino (Oulu University
Library, Finland) kindly helped us with the systematic literature
search by providing her knowledge in using the Medline-database and
finding the suitable search terms. This study was supported by
research grants by the Foundation of the Finnish Anti-Tuberculosis
Association, Väinö and Laina Kivi Foundation, Ida Montin Founda-
tion, the Oulu University Hospital, and The Academy of Finland
Grants No. 129419 (SALVE Research Program) and No. 138691.
Conflict of interest The authors declare that they have no conflict
of interest.
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