Effects of a Progressive Exercise Program on Absenteeism Among School Children with Asthma* Michael R. Schneider Beth H. Melton Joan S. Reisch

INTRODUCTION Asthma is a reversible disease causing intermittent air-

way obstruction which is manifested to the patient by shortness of breath and wheezing. Children may suffer mild, infrequent attacks or severe, sudden attacks requiring medication and hospitalization. At least 2 to 3% and perhaps as many as 4 to 7% of all school-age children in the United States, approximately two million children, at some time suffer from asthma. The American Academy of Pediatrics Committee on Children with Handicaps states that the condition accounts for more school absenteeism than any other chronic disease.'*2 Asthma has also been found to be more common among males. 3*4

Until recently, asthmatic children were restricted to limited physical activities. Howe;er, research by Itkin, McElhenny and Peterson,6 Rule and Scherr indicates that children with asthma can participate in physical activities the majority of the time if under proper medical management. The American Academy of Pediatrics advises a full program of physical activity with a minimum of restriction^.^'^

Studies assessing the impact of systematic exercises in children with asthma have dealt largely with camps or classes which have artificially isolated the children from their peers. This study was undertaken to determine the impact of regular physical conditioning conducted in a public school environment. The parameters used to evaluate the program were school absenteeism of children with moderate asthma and an index of the severity of attacks of asthma. The study group was compared to a control group of asthmatic children in a contiguous school district without a special exercise program.

*The study was conducted by the American Lung Association-Dallas Area with grant monies from the Carl B. and Florence E. King Foundation; General Mills Foundation; Blanche Mary Taxis Foundation as well as other private donations.

THE STUDY Two school systems in Eastern Dallas County were

chosen for evaluating the exercise program: the Garland Independent School District and the Mesquite Inde- pendent School District. These school systems were selected for their willingness to participate; similar numbers of asthmatic children; daily physical education classes for grades 3 to 5 ; and their geographic proximity which implies similar environmental conditions.

All children in the Garland School District in grades 3 to 5 participated in the exercise program for 3 to 5 minutes at the beginning of their daily physical education classes. Studies show five-minute exercise periods are generally accepted as an appropriate length of time for an asthmatic to exercise, alternated with rest periods or less strenuous activities. 'O*" The exercises are designed to strengthen muscles used in breathing but are also beneficial to children without breathing disorders. For children in grades 3 to 5 in the Mesquite School District, the control group, the daily physical education program was not altered.

As a basis for measuring the success of the exercise program, absenteeism and severity of attack were examined for students with moderate asthma in both the study group (Garland) and the control group (Mesquite). The criteria for inclusion in the moderate asthmatic group was that the child was taking a prescription drug and thus assumed to have been diagnosed as asthmatic by a physician. Records were kept for four eight-week periods for each year of the two-year study.

Criteria shown in Table 1 were utilized in assessing the severity of an asthma attack which necessitated the student's absence from school. It can be seen that increasingly positive scores are associated with in- creasingly severe asthma attacks. This scale follows the approach of Scherr, et a1.I2

Additional staff was hired by the American Lung Association to perform various functions in Garland

92 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1 980

TABLE 1 Criteria Used to Determine Severity of Attack

and Reason for Absence

Student is taken from home or school to doctor, hospital or clinic. He is admitted as either an in or out patient.

5

Treatment of an asthma attack Seventy Score 1

Student is taken from home or school to doctor, hospital or clinic and is treated for an asthma attack and released.

4

Student is administered a curative 3 drug at home or school other than normal daily or weekly prescribed preventative drug requirements.

Student controls an asthma attack 2 with normal daily or weekly pre- ventative medication and does not exceed daily or weekly dosage.

Student controls an asthma attack 1 with breathing exercises and water.

~~~ ~~ ~ ~

during this study. An Adapted Physical Education In- structor was hired to supervise the staff of the physical education instructors regarding physical exercises for all children in the study group, teach, consult and conduct in-service training sessions for the physical education staff. They also hired a School Nurse to contact parents of the study group by phone to acquire baseline data, provide parent consultation and coordinate the parent education meetings. School nurses in Mesquite initially contacted the parents of the children in the control group. A Data Clerk contacted schools for the names of absentees and then phoned parents of absent children in both groups to determine the reason for the absence and the severity of the attack according to the criteria in Table 1.

For purposes of this study, the investigators restrict participants to those with moderate asthma because that involved the majority of children available for both groups. Positive and negative manifestations affecting the asthma of this population were more frequently observed in this group.

The number of children with moderate asthma in the Garland study was 100 for the 1967-77 school year and 86 in Mesquite. In the second year of the study, 99 Garland students from grades 3 to 5 took part in the study while 74 Mesquite children participated. Some third and fourth grade students from both school districts appear in the second year as fourth and fifth graders.

Early in the program planning, members of the Garland medical communities were contacted by three

physicians supporting the program. They spoke at hospital staff conferences to elicit physician support. In addition, a letter was sent to each physician listed on Garland school health records, explaining the program and encouraging the physician to allow full participa- tion of his patient. No deliberate contact was made with Mesquite physicians in an attempt to ensure that the physicians treating moderate asthmatic children in Mesquite would not be influenced to change the medical or exercise regimen of their patients as a result of their knowledge of the ongoing study.

Parental support was considered to be dependent upon their awareness of the program and its goals. The three parent meetings held in Garland during the first year included: a demonstration of the exercise program with a physician and a staff member from the Lung Association present to discuss the program; a discussion of the effects of air pollution on children with asthma; and a discussion of the psychological aspects of asthma. During the second year, an initial parent meeting was held in Garland to explain the program. This was followed by exercise demonstration meetings by asthmatic and non-asthmatic children. Their purpose was to demonstrate the ability of the child with asthma to participate as fully as his non-asthmatic peer.

The curriculum was designed from sources regarding the benefits of gymnastics and The back- ground training and practical knowledge of the Adapted Physical Education Instructor, an asthmatic himself, also provided valuable input!* The curriculum was patterned to include progressive exercises for the abdominal muscles, upper and lower back muscles, general conditioning and breathing exercises. The exercise program utilized diaphragmatic deep breathing since this has been shown to reduce anxiety, increase one’s confidence in taking care of oneself during an attack of asthma and help in controlling wheezing attacks.” Repeated practice followed demonstration of the techniques. Students progressed from mild to moderate to strenuous exercises, increasing the number of exercises and the length of time for each one. The curriculum did not encourage competition among peers.

After 3 to 5 minutes of this exercise program, all students continued the regular physical education program. Children with asthma were encouraged to participate to the best of their capabilities. If wheezing occurred, the child was encouraged to practice diaphragmatic breathing. When indicated by a physi- cian, the child was given medication prior to physical education classes. It was not determined which children received medication.

Average numbers of days absent and a weighted severity score were used as measures for comparison of the two groups. Severity was assessed using a weighted score which utilized the product of the severity of attack and the number of days absent summed over all four time periods. Groups were compared on these two variables for each of the years using Student’s t test for independent groups.

FEBRUARY 1980 THE JOURNAL OF SCHOOL HEALTH 93

RESULTS One hundred children in grades 3 to 5 in 30 schools in

the Garland School District participated in the exercise program the first year, while 86 children in 16 Mesquite schools served as the control group. Differences in absenteeism and severity of attack were selected as indicators of possible differences between the two groups. No significant differences between groups were found for either the sex or grade distribution. Chi square contingency table analyses were used for these comparisons.

The average age of students in the exercise group was 9.44 years with a standard deviation (SD) of 0.92, while the average age in the control group was 9.53 years, SD = 1.03. Using Student’s t test comparison of two independent means, no significant difference was found (t = 0.63, df = 184, p = 0.53). Thus, on the basis of sex, grade and age, both groups were similar.

Similar conclusions can be drawn about the composition of both groups in the second year of the study. Chi square contingency table analyses revealed nonsignificant differences between groups. There were 99 students from 3 1 Garland schools in the second year and 74 from 16 Mesquite schools.

The average age for both groups in the second year was remarkably similar. In the Garland study group, the average age was 9.40 years with a SD = 0.85 and the Mesquite control group had an average age of 9.52 years with a SD = 1.03. Thus, for both years the two groups were similar in sex, age and grade distribution.

Average number of days absent for each time period and overall during the first study year are shown in Table 2. The average number of days is consistently higher for the Mesquite control group for each of the four eight-week time periods as well as overall. The overall difference was significantly higher in the control group which averaged 5.36 days absent (SD = 6.14 days), while the study group averaged 2.21 days absent (SD = 3.03 days). Using Student’s t test for independent means, the difference was significant at the 0.001 level (t = 4.53, df = 184, p = 0.OOOl).

hesquite X .76 .73 .SO .88 2.86 N = 74 SD 1.26 2.25 1.23 1.85 4.40

h

TABLE 2 Average Days Absent During Year 1

Period Overall 1 rp arland 1 ::3 .:5 .:5 .:8 2.21 I N = 100 SD 1.24 .91 1.53 1.05 3.03

esquite 1.71 1.12 1.67 .86 5.36 N = 86 SD 2.55 2.14 2.63 1.64 6.14

It was found that 53 of the 100 students in the Garland study group accounted for all of the absences in that group, while 62 (72.1 Yo) of the 86 students in the Mesquite control group had one or more absences. Thus, the percent of students with no absences during

all study periods was significantly lower in the study group (x2 = 6.36, df = 1 , p = 0.012).

In the first year, the average of the weighted severity score for the study group was 5.88 with SD = 9.12 while the control group averaged 16.44 with SD = 20.32. The weighted severity score was significantly lower in the study group (t = 4.68, df = 184, p = 0.001).

Results of the absenteeism data for the second year are shown in Table 3. In two of the four time periods, the study group had fewer absences on the average than did the control group. In the fourth time period they were almost equal. Overall, the average number of absences in the control group was slightly higher than the study group. This difference, while favoring the study group, is not statistically significant. (t = 0.51, df = 171, p = .611).

TABLE 3 Average Days Absent During Year 2

Period Overall 1 2 3 4 -

arland x .88 .41 .37 .90 2.57 N = 99 SD 1.44 1.05 1.03 1.69 3.08

94 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1980

year were not statistically significant. Some possible explanations of the second year’s results are: (1) Increased awareness among the parents of the control group members may have prompted more attention for the asthmatic child, thus possibly altering the frequency and/or severity of the attacks in children whose asthma was aggravated by psychological factors. This increased awareness could be a result of newspaper stories, TV programs and public speeches by the Lung Association personnel about the exercise program. This same media exposure for the Garland parents may have served to reinforce principles to which they had already been introduced. (2) The physical education teachers of the control group may have become aware of the program as a result of professional contacts and subsequently altered their physical education program. (3) Children in the Mesquite control group may have been treated by physicians who were aware of the study and who may have altered their treatment regimen.

RECOMMENDATIONS After conducting and evaluating a two-year program

of breathing exercises and progressive physical exer- cises, the investigators recommend the following when considering future studies: (1) Provide class time to integrate and lengthen the program as part of the physical education curriculm rather than just a preliminary activity, (2) offer before and after school programs, and (3) examine the same parameters in grades K-2 and 6-12.

REFERENCES

1. Evans HE: What happens when a child has asthma. Am Lung

2. American Academy of Pediatrics Committee on Children with

3. Williams HE, Phelan PD: Respiratory Illness in Children.

4. Evans HE: Lung Diseases of Children. New York, American

5 . Itkin IH: The pro’s and con’s of exercise for the person with

Assoc Bulletin 7, March 1979.

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Oxford; Blackwell Scientific Publication, 1975, p 121.

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asthma. Am J Nurs 66:1584-1587, 1966.

6. McElhenny TR, Peterson KH: Physical fitness for asthmatic

7. Rule RA: Exercise for asthmatics - a pilot program. J Phys Ed

8 . Scherr MS: Physical conditioning program for asthmatic

9. Fitch KD: Exercise induced asthma and competitive athletics.

10. Ghory JE: Exercise, the school and the allergic child. Pediatrics

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feedback techniques on chronic asthma in a summer camp environ- ment. Annals of Allergy 39291, 1975.

13. Asthma: A Comprehensive Approach Through Exercise - An Adjunct to Medical Therapy. Dallas, Texas, American Lung Association-Dallas Area, 1975.

14. O’Quinn G Jr: Gymnastia for Elementary School Children. Austin, Department of Physical Education and Health Education, University of Texas, 1973.

15. Kirchner G: Physical Education for Elementary School Children. Dubuque, Iowa, Wm C Brown Co, 1966.

16. Fait HF: Special Physical Education. Adapted, Corrective, and Developmental. Philadelphia, WB Saunders Co, 1972.

17. Sherrill C: Adapted Physical Education and Recreation. A Multid&ciplinary Approach. Dubuque, Iowa, Wm C Brown Co, 1976.

18. Schneider MR: Intensive Physical Conditioning for Asthmatic Children and Changes in Selected Pulmonary Measures, thesis. Denton, Texas, Texas Woman’s University, 1977.

19. Breathing and physical fitness exercises for asthmatic children. Pediatric Clinical North America 16:31-42, 1969.

Mike R . Schneider, MA, is the Adapted Physical Education Instructor, Garland Independent School District, Garland, TX 75040. Beth H. Melton, MA, is the Program Director, American Lung Association- Dallas Area, 3925 Maple Avenue, Dallas, TX 75219 (Corresponding author). Joan S. Reisch, PhD, is an Assistant Professor of Biostatistics in the Department of Medical Computer Science and Manager of the Biometrics Section of the Medical Computing Resources Center at the University of Texas Health Science Center at Dallas, 5323 Harry Hines, Dallas, TX 75235.

boys. JAMA 185:142-143, 1957.

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children. JAMA 168:1996-2OO0, 1958.

Pediatrics 56(suppl):943, 1975.

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Advances in Pediatric Nursing Symposium March 13-14, 1980

The School of Nursing at the University of California, San Francisco is sponsoring this two-day symposium. The focus will be on current issues and clinical advances in both ambulatory and acute care pediatric nursing practice using a multidisciplinary approach. A variety of group sessions will be offered.

One unit of credit (12 hours) will be offered and the fee is $100.00. For further infor- mation, please contact S. Herzog, Continuing Education in Nursing, N43 1, University of California, San Francisco, CA 94143 or call (415) 666-1817.

FEBRUARY 1980 THE JOURNAL OF SCHOOL HEALTH 95