IAFC 2011 Asthma and Aquatic Exercise

Exercise has been shown to have extensive health benefits both in normally functioning 
adults as well as in adults with asthma.[1, 2] Despite research demonstrating the utility 
of aquatic exercise in asthmatic individuals, such use is not widespread. Aquatic 
exercise may also benefit the multiple other physiologic problems commonly found in 
asthmatic individuals.[3] Asthmatic individuals commonly have suboptimal 
cardiorespiratory function as well as other metabolic risk factors that are exercise­
remediable.[1] A program of regular aquatic exercise may have unique benefits in the 
asthmatic population because of the known aerobic capacity development typical of 
such programs,[4] combined with the unique value of immersion­produced 
improvements in respiratory endurance and cardiac output.[5­8] In addition, there may 
be clinically important gains in daily function as well as an increase in exercise­
produced anti­inflammatory cytokines.[9, 10]

In 2006 we completed a study comparing respiratory fatigue in healthy university 
students, with one group in a 3­times weekly aquatic exercise program, and the other 
group in a matched land­based aerobic exercise program.[12] Based upon the results of 
this research, we have been training Washington State University teams using a 
program of vigorous deep­water aerobic exercise. Previous studies have shown that 
programs focusing on respiratory endurance have improved athletic performance 
significantly.[13, 14] Interestingly, as respiratory fatigue occurs, the body responds with 
a metaboreflex that diverts blood from the lower extremities to the survival­critical 
muscles of respiration, which has the effect of worsening lower extremity fatigue and 
decreasing lower extremity strength and endurance.[15] 

Many studies have researched the value of aerobic exercise training in asthmatic 
individuals. The value of exercise throughout the lifespan in general health 
maintenance and health preservation is well recognized, with a substantial research 
support base.[16, 17] While there is controversy over the value of exercise in 
progression of asthma or in the underlying pathophysiology, a recent Cochrane review 
concluded that there is little reason to proscribe exercise in asthmatic individuals and 
good reasons to recommend it given the overall health benefits.[18] This review showed 
that cardiopulmonary fitness and some measures of lung function were significantly 
improved although no reductions in days of wheezing were found.

Previous studies in asthmatic individuals have shown a sub­normal exercise 
tolerance[2] and several studies have demonstrated poor physical fitness.[19­21] One of 
the probable causes in reduced exercise tolerance is respiratory fatigue, and primarily 
diaphragmatic fatigue.[22] A generalized loss of muscle bulk, compounded by steroid 
therapy may also result in respiratory weakness. Improvement in inspiratory function is 
quite dependent upon diaphragm function.[23] Neck depth immersion places the 
diaphragm at increased length.[24­26] As a result, this muscle may work through its 
entire length­tension relationship and if working against a workload, will show 

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 IAFC 2011 Asthma and Aquatic Exercise

improvement in strength and fatigue tolerance. Improvement in respiratory muscular 
and cardiorespiratory endurance is postulated as the primary reason for the clinical 
improvement seen in asthmatics, as studies usually do not find significant lung function 
changes.[18] While several studies assessing the value of inspiratory strengthening in 
asthma have shown improvement in some lung measurements, particularly PImax, a 
2003 Cochrane review of these studies concluded that further research was needed to 
assess the clinical value of such techniques as inspiratory muscle strengthening has 
potential to reduce dyspnea and need for beta­2 agonists.[27] 

The relationship between asthma, depression and anxiety is quite well established with 
a significantly higher percentage of asthmatics demonstrating emotional distress 
symptoms than their age­related peer non­asthmatics.[28­31] Emotional stress has been 
well accepted as an asthma trigger for years. Asthmatics with high anxiety scores have 
greater difficulty controlling their asthma, whereas less anxious asthmatics have 
lowered sense of dyspnea.[30] This effect is almost certainly regulated by the autonomic 
nervous system (ANS.) The ANS greatly affects all cardioregulatory processes, 
producing characteristic alterations in heart rate variability. Patterns of heart rate 
variability are highly related to emotional status, and exercise has been shown to 
positively affect autonomic nervous system balance.[32, 33] Exercise both on land and 
in water has been shown to have a positive effect upon anxiety and depression.[34, 35]

Aquatic activity has been stated to have a low asthmogenicity, in part because of the 
warm very humid pollen­free layer of air over the water.[36, 37] Consequently both an 
improvement in general conditioning can be achieved with its associated health benefits 
as well as a reduced incidence of exertionally­induced asthma (EIA). Swimming has 
consequently been widely promoted as an exercise regimen for individuals with 
asthma.[3, 4, 36, 38­46] Despite these many recommendations, relatively few studies 
have assessed the impact of a deep­water aerobic aquatic exercise program in its effect 
upon VO2max, % body fat, quality of life and serial respiratory studies. Neither our 
group nor the Cochrane investigators could find studies that assessed aquatic exercise 
effects in these variables in a large population of individuals. Pulmonary hyperinflation, 
a common asthmatic condition, may also be diminished during neck depth immersion 
due to the hydrostatic pressure of the water upon the thorax, combined with the 
reduction in expiratory reserve volume.[8, 47]
 
The relationship between asthma and obesity has been extensively researched, although 
the nature of the relationship remains poorly understood.[48­50] Whether obesity 
precedes or follows an asthmatic diagnosis appears to be the major point of 
controversy.[48] Nonetheless, there is evidence that reduction in body fat percent has a 
positive effect upon asthma symptoms.[50] Aquatic exercise has been widely used in 
the promotion of exercise in obese individuals.[51] The advantages of aquatic exercise 
include reduced joint loading, improved muscle blood flow, improved respiratory 

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 IAFC 2011 Asthma and Aquatic Exercise

function, and ease of movement.[51­54] Our previous research showed a very 
significant decrease in percent body fat in both the aquatic aerobic exercise group and 
our land­based control group.

There are biomechanical differences between swimming and vertical water exercise. 
Swimming is a technically difficult skill, and because of individual variances in skill 
level between swimmers, energy consumption and training effectiveness are more 
difficult to regulate. Vertical water exercise using a flotation belt can be easily 
monitored and regulated, making a more homogenous training environment, with less 
individual variance in energy consumption than in a swimming exercise group, some of 
whom may have efficient stroke technique and others who struggle inefficiently. We 
chose to use a vertical deep water exercise protocol because of the easier learning curve, 
the ability to more closely monitor exercise intensity, and particularly because of the 
added hydrostatic pressure of the water upon the chest wall.

The hypothesis of our study was that the basic physiologic changes inherent to aquatic 
exercise combined with the pathophysiology of asthma through a program of weekly 
aquatic exercise could potentially produce a measurable and statistically significant 
effect upon aerobic fitness, respiratory muscular strength, asthma disability, activities of 
daily living, percent body fat, and quality of life in a group of asthmatic individuals. We 
studied a group of 16 asthmatic adults over a 12 week program of progressively intense 
vertical aquatic exercise. We found that these individuals lost body fat percentages in 
significant amount, improved in lean body mass, improved in cardiorespiratory fitness 
measures, and improved in subjective asthmatic status, but showed no changes in 
medication use, nor did they show measurable change in inflammatory cytokines, 
respiratory function measurements, blood lipids, or sleep patterns. No adverse events 
due to asthma occurred through the study, and the study participants found the 
exercise regimen both helpful and pleasurable. While our research results demonstrated 
a positive impact on some of the study variables, the study group was both more fit at 
onset and less impacted by asthma than the literature led us to believe was typical of 
asthmatic groups.

Summary
Asthma as a chronic disease has a very significant impact upon an individual’s quality 
of life.[56] While asthma may be life­threatening at times, the day­to­day management 
as in many chronic diseases proves burdensome. The active avoidance of activities that 
may provoke an attack often limits the asthmatic from embarking upon activities that 
would be healthy and beneficial. Many of the health factors contributing to increased 
morbidity and mortality in inactive individuals are common in asthmatic populations, 
including the metabolic syndrome and obesity, as referenced above. Thus physical 
activity is very important for asthmatics. Aquatic exercise has been widely promoted 
for asthma sufferers, but usually as swimming. We have not been able to identify 

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 IAFC 2011 Asthma and Aquatic Exercise

studies that have assessed a structured vertical aquatic exercise program on asthma 
impact, VO2max, body fat%, inflammatory cytokines, and quality of life. There is reason 
to believe that such a program would show clinically important improvements in these 
factors, outside of purely pulmonary function parameters. Our project leads us to 
believe that a larger study might demonstrate improvement in more of these variables. 
Because of the exercise protocol design, many asthmatics could access such a program, 
because community pools and aquatic exercise classes are widely available, the 
techniques and exercise protocols do not require swimming skill, are simple to teach 
and learn, and are very safe and enjoyable.

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