The effects of pulmonary rehabilitation with chronic obstructive pulmonary disease (COPD)]

It is controversial whether pulmonary rehabilitation is effective in patients with chronic obstructive pulmonary disease (COPD). To test the effect of pulmonary rehabilitation, 7 patients with COPD (aged 76.0 +/- 2.6 years) were enrolled in pulmonary rehabilitation program for 6 weeks. The program consisted of relaxation, pursed lip breathing, diaphragmatic breathing, panic control, muscle stretch gymnastics, and exercise training. The distance of the 6-minute walking test increased significantly from 246.4 +/- 38.0 (m) to 304.3 +/- 28.4 (m) (p < 0.05). The minimum SpO2 during the 6-minute walking test increased from 86.0 +/- 2.8 (%) to 90.1 +/- 1.3 (%) and dyspnea as measured with Borg scale decreased from 5.6 +/- 1.1 to 4.6 +/- 0.5, although they were not significantly different. These results suggest that pulmonary rehabilitation might improve exercise tolerance in elderly patients with COPD.     

Benefits of a multidisciplinary pulmonary rehabilitation program. Improvements are independent of lung function

We evaluated the conditions of 33 patients who completed an outpatient pulmonary rehabilitation program to determine what types of improvements occurred, and whether these changes were related to the baseline degree of ventilatory impairment, to determine whether rehabilitation was beneficial to patients, regardless of the degree of underlying lung dysfunction. Endurance measurements, including sustained submaximal performance on a cycle ergometer and the 12-minute walk distance (1,349 +/- 625 feet to 1,700 +/- 670 feet) increased significantly (p less than 0.01), as did multiple educational and subjective parameters. Maximal exercise performance on a graded cycle test improved very little, with a decline in the ventilatory equivalent for oxygen consumption (VE/VO2) being the only significant change (48.2 +/- 28.3 L/ml to 36.6 +/- 8.7 L/ml). Of the observed changes, only one endurance measurement, the sustained submaximal exercise performance, correlated with FEV1 (r = 0.5, p less than 0.01), but only if it was expressed as an absolute number (liters) and not as percent predicted. Lung function did not correlate with changes in the 12-minute walk distance, in maximal exercise performance on the cycle ergometer or with changes in educational and subjective parameters. We conclude that because the magnitude of change in both physiologic and psychologic parameters was not directly related to lung function, the benefits of rehabilitation can extend to all patients with chronic lung disease, regardless of the severity of preexisting pulmonary dysfunction.     

Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial

PURPOSE: Pulmonary rehabilitation programs are effective in patients with severe chronic obstructive pulmonary disease (COPD) in the short term, but their long-term effects are not known. We investigated the short- and long-term effects of a 6-month outpatient rehabilitation program in patients with severe COPD. SUBJECTS AND METHODS: One hundred patients were randomly assigned to receive either an exercise training program that included cycling, walking, and strength training (n = 50) or usual medical care (n = 50). Thirty-four patients in the training group were evaluated after 6 months (end of training), and 26 were evaluated after 18 months of follow-up. In the control group, 28 patients were evaluated at 6 months and 23 after 18 months. We measured pulmonary function, 6-minute walking distance, maximal exercise capacity, peripheral and respiratory muscle strength, and quality of life (on a 20 to 140-point scale), and estimated the cost-effectiveness of the program. RESULTS: At 6 months, the training group showed improvement in 6-minute walking distance [mean difference (training - control) of 52 m; 95% confidence interval (CI), 15 to 89 m], maximal work load (12 W; 95% CI, 6 to 19 W), maximal oxygen uptake (0.26 liters/min; 95% CI, 0.07 to 0.45 liters/min), quadriceps force (18 Nm; 95% CI, 7 to 29 Nm), inspiratory muscle force (11 cm H(2)O; 95% CI, 3 to 20 cm H(2)O), and quality of life (14 points; 95% CI, 6 to 21 points; all P <0.05). At 18 months all these differences persisted (P <0.05), except for inspiratory muscle strength. For 6-minute walking distance and quality of life, the differences between the training group and controls at 18 months exceeded the minimal clinically-important difference. CONCLUSION: Among patients who completed the 6-month program, outpatient training resulted in significant and clinically relevant changes in 6-minute walking distance, maximal exercise performance, peripheral and respiratory muscle strength, and quality of life. Most of these effects persisted 18 months after starting the program.     

Characteristics of physical activities in daily life in chronic obstructive pulmonary disease

Quantification of physical activities in daily life in patients with chronic obstructive pulmonary disease has increasing clinical interest. However, detailed comparison with healthy subjects is not available. Furthermore, it is unknown whether time spent actively during daily life is related to lung function, muscle force, or maximal and functional exercise capacity. We assessed physical activities and movement intensity with the DynaPort activity monitor in 50 patients (age 64 +/- 7 years; FEV1 43 +/- 18% predicted) and 25 healthy elderly individuals (age 66 +/- 5 years). Patients showed lower walking time (44 +/- 26 vs. 81 +/- 26 minutes/day), standing time (191 +/- 99 vs. 295 +/- 109 minutes/day), and movement intensity during walking (1.8 +/- 0.3 vs. 2.4 +/- 0.5 m/second2; p < 0.0001 for all), as well as higher sitting time (374 +/- 139 vs. 306 +/- 108 minutes/day; p = 0.04) and lying time (87 +/- 97 vs. 29 +/- 33 minutes/day; p = 0.004). Walking time was highly correlated with the 6-minute walking test (r = 0.76, p < 0.0001) and more modestly to maximal exercise capacity, lung function, and muscle force (0.28 < r < 0.64, p < 0.05). Patients with chronic obstructive pulmonary disease are markedly inactive in daily life. Functional exercise capacity is the strongest correlate of physical activities in daily life.     

Regular walking and long-term maintenance of outcomes after pulmonary rehabilitation

BACKGROUND: Empirical evidence supports the role of exercise as part of pulmonary rehabilitation in improving symptoms of breathlessness (dyspnea), health-related quality of life, and exercise tolerance among patients with chronic lung disease. However, many studies show that these initial benefits tend to diminish 12 to 18 months after rehabilitation. Given the importance of exercise (ie, walking) during rehabilitation, we examined whether patient adherence to regular walking enhanced the long-term maintenance of functional benefits gained from an 8-week pulmonary rehabilitation program. METHODS: One hundred twenty-three patients with moderate to severe chronic lung disease completed an 8-week pulmonary rehabilitation program and participated in a 12-month maintenance intervention trial. Measures of weekly walking, lung function, self-efficacy for walking, dyspnea during activities of daily living, exercise capacity (6-minute walk test, 6MW), perceived breathlessness after the 6MW, and health-related quality of life were obtained at postrehabilitation, and at 6, 12, and 24 months after completing pulmonary rehabilitation. Regular walkers were defined as those active on most days or every single day of the week on the average throughout the 24-month period, whereas irregular walkers walked on some days, rarely, or not at all. RESULTS: The effects of the maintenance program on average frequency of walking were nonsignificant, with 44% of the maintenance patients and 38% of the standard care patients classified as regular walkers. There were no significant differences between walking groups on gender, healthcare utilization over the 24-month follow-up period, and postrehabilitation measures of lung function, 6MW distance, perceived breathlessness after 6MW, health-related quality of life, dyspnea, or age. Repeated measures analyses of variance using a 2 x 4 mixed model approach were applied to examine group differences and changes in outcomes over time. Overall, participants decreased in 6MW distance (P <.001), reported increases in perceived breathlessness after the 6MW (P <.05), and decreased in overall health-related quality of life (P <.001) from postrehabilitation to 24 months. Regular walkers reported significantly better health-related quality of life (P <.05) as compared to irregular walkers, averaging across time points. Irregular walkers declined significantly more than regular walkers on measures of shortness of breath during activities of daily living (P <.01) and walking self-efficacy (P <.001) from postrehabilitation to 24 months. CONCLUSIONS: Findings suggest that participation in regular exercise such as walking after completing pulmonary rehabilitation is associated with slower declines in overall health-related quality of life and walking self-efficacy as well as less progression of dyspnea during activities of daily living. Regular exercise after rehabilitation may be protective against increases in dyspnea symptoms and perceived limitations in walking which are both characteristic of progressing chronic lung disease.     

Effect of pulmonary rehabilitation on quality of life in patients with COPD: the use of SF-36 summary scores as outcomes measures

PURPOSE: Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR. METHODS: Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores. RESULTS: The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002). CONCLUSION: The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.     

Low body mass index and exercise capacity in patients with chronic obstructive pulmonary disease (COPD)]

This study examined retrospectively the relationships between body weight and exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Seventeen patients with a %FEV1 less than 55% (mean +/- SD 36% +/- 8.8%) and minimum body weights of the body mass index (BMI) less than 20 (17.3 +/- 1.7) performed incremental exercise testing using a treadmill. Seventeen %FEV1-matched control patients with normal body weights were selected. There were no significant differences in the patients' characteristics or their pulmonary function tests (including vital capacity, carbon monoxide diffusing capacity, and arterial blood gases). Low BMI patients Is this the weaning of (67.8 +/- 6.3 years old) were younger than the control patients (73.1 +/- 8.5 years old), but the difference was not statistically significant. The exercise capacities of low BMI patients were significantly superior to those of the control patients (316.5 +/- 171.5 seconds vs 204.1 +/- 116.3 seconds, p = 0.038) and total walking distance without statistical significance (194.9 +/- 117.0 m vs 125.7 +/- 98.0 m, p = 0.071). Also, low BMI patients achieved higher maximal minute ventilation volume during exercise than the controls. The major factor limiting exercise in patients with low BMI was ventilation. Moderately low body weight may not be a risk factor in Japanese COPD patients.     

Feasibility and efficacy of home exercise training before lung volume reduction.

BACKGROUND: Exercise training is recommended before lung volume reduction surgery (LVRS) in patients with emphysema. Unfortunately, many of these patients are referred from remote areas where there is no available rehabilitation program. The authors evaluated the feasibility and efficacy of a minimally supervised home-based exercise training program. METHODS: Twenty-three emphysematous patients (age 61 +/- 6, forced expiratory volume in 1 second = 29 +/- 7% predicted [mean +/- SD]) were recruited from our LVRS program. Measurements of pulmonary function, maximal and submaximal exercise capacity, 6-minute walking distance (6-MWD), muscle strength, and quality of life with the Chronic Respiratory Questionnaire were obtained before and after training. Home-based exercise training program included muscle exercises and aerobic training, and started with detailed teaching while the follow-up was ensured through weekly phone calls and a diary filled by each patient. RESULTS: Significant increases in 6-MWD (P < 0.001), quality of life (P < 0.005), peak work rate (P < 0.05), peak oxygen consumption (P < 0.05), endurance time (P < 0.005), and muscle strength were observed in the home-based exercise training program. CONCLUSIONS: Home-based exercise training for patients in preparation for LVRS was feasible, and induced significant improvement in exercise tolerance and quality of life.     

运动康复训练对老年慢性心力衰竭患者预后的影响

目的探讨运动康复训练对老年慢性心力衰竭患者预后的影响。方法65例老年慢性心衰患者随机分为干预组33例和对照组32例。对照组给予常规治疗,干预组在常规治疗基础上采用运动康复训练,疗程均为8周。结果治疗8周后,干预组较对照组左室射血分数增加、NYHA心功能改善、6 min步行距离延长（P均〈0.05）;随访12个月后干预组较对照组生活质量明显提高（P〈0.05）,因心衰再入院率降低（P〈0.05）;干预组患者康复训练中未发生心衰加重、恶性心律失常等不良事件。结论对老年慢性心力衰竭患者实施运动康复训练安全有效。     

The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-stage chronic obstructive pulmonary disease

OBJECTIVE: To evaluate the functional impact of an individualized outpatient pulmonary rehabilitation program in end-stage chronic obstructive pulmonary disease (COPD). METHODS: Patients with end-stage COPD were admitted into a 6-week comprehensive outpatient pulmonary rehabilitation program that was "packaged" for each patient. We compared spirometric parameters, exercise tolerance, level of breathlessness, and intensity of work before and after rehabilitation. RESULTS: Of 45 eligible patients, only 14 consented to participate in the study. All 14 patients had forced expiratory volume in 1 second <35% of predicted, and 10 patients (72%) had a 6-minute walk test <180 m. The level of breathlessness was between 7 (moderate to severely breathless) and 10 (maximally breathless) on the Visual Analogue Scale in all patients. After the program, there was significant improvement in the FEV 1 P = 0.04), forced vital capacity P = 0.0045), 6-minute walk test P = 0.00047), and shuttle-walk test (9 of 14 patients). All patients had some improvement in level of dyspnea. CONCLUSIONS: Individualized outpatient pulmonary rehabilitation in end-stage COPD can produce a measurable improvement in spirometry and exercise tolerance with a favorable impact on the level of physical activity.     

Responsiveness of three instruments to assess self-reported functional status in patients with COPD

The study aimed to compare the responsiveness of three instruments to assess self-reported changes in functional status after exercise training in patients with COPD: Pulmonary Functional Status and Dyspnea Questionnaire -modified version (PFSDQ-M), London Chest Activity of Daily Living (LCADL) and Medical Research Council scale (MRC). Twenty-two patients (11 female, 66[62-71] years, FEV1 42[33-61]%predicted) participated in a 3-month high-intensity exercise program. The three instruments were applied pre- and post-program, as well as assessment of lung function, muscle strength, exercise capacity (6-minute walking test, 6MWT) and quality of life (St. George's Respiratory Questionnaire, SGRQ). SGRQ, 6MWT and quadriceps femoris, biceps and triceps brachialis strength improved significantly after the program (p < 0.05 for all). Training also yielded significant improvement in the LCADL total score and self-care, domestic and leisure domains and in the PFSDQ-M 'change in activities' domain, with no improvement in the MRC (p = 0.11). Calculation of effects sizes also indicated higher responsiveness in the LCADL than the other instruments. There were no significant correlations between changes in the three instruments and changes in lung function, SGRQ or 6MWT. In conclusion, PFSDQ-M's 'change in activity' domain and specially the LCADL (to a higher extent) showed responsiveness to detect changes in functional status after three months of high-intensity exercise training in patients with COPD, whereas the MRC scale did not. In this population, the improvement in functional status was not related with improvement in exercise capacity, lung function or quality of life.     

Are patients with COPD more active after pulmonary rehabilitation?

BACKGROUND: Despite a variety of benefits brought by pulmonary rehabilitation to patients with COPD, it is unclear whether these patients are more active during daily life after the program. METHODS: Physical activities in daily life (activity monitoring), pulmonary function (spirometry), exercise capacity (incremental cycle-ergometer testing and 6-min walk distance testing), muscle force (quadriceps and handgrip force, and inspiratory and expiratory maximal pressures), quality of life (chronic respiratory disease questionnaire), and functional status (pulmonary functional status and dyspnea questionnaire-modified version) were assessed at baseline, after 3 months of a multidisciplinary rehabilitation program, and at the end of a 6-month multidisciplinary rehabilitation program in 29 patients (mean [+/- SD] age, 67 +/- 8 years; FEV(1), 46 +/- 16% predicted). RESULTS: Exercise capacity, muscle force, quality of life, and functional status improved significantly after 3 months of pulmonary rehabilitation (all p < 0.05), with further improvements in muscle force, functional status, and quality of life at 6 months. Movement intensity during walking improved significantly after 3 months (p = 0.046) with further improvements after 6 months (p = 0.0002). Walking time in daily life did not improve significantly at 3 months (mean improvement, 7 +/- 35%; p = 0.21), but only after 6 months (mean improvement, 20 +/- 36%; p = 0.008). No significant changes occurred in other activities or in the pattern of the time spent walking in daily life. Changes in dyspnea after the program were significantly related to changes in walking time in daily life (r = 0.43; p = 0.02). CONCLUSION: If one aims at changing physical activity habits in the daily life of COPD patients, the contribution of long-lasting programs might be important.     

Effect of sustained release of theophylline on pulmonary physiologic function in elderly patients with chronic obstructive pulmonary disease

We tested the effects of the sustained release of theophylline on the physiologic function of the respiratory system in elderly patients with chronic obstructive pulmonary disease (COPD). We measured the pulmonary function, static respiratory pressures, and ventilation during exercise, before and after the administration of sustained release of theophylline. Unifil, in 12 male COPD patients (mean age 82.1 +/- 0.6 years old). Forced expiratory volume in one second was increased by the administration of 400 mg of Unifil, but not by 200 mg of Unifil, whereas the ratio of residual volume to total lung capacity was decreased by the administration of 400 mg Unifil. Maximum inspiratory pressure was significantly increased after the administration of 400 mg of Unifil. Dyspnea sensation during exercise assessed by the Borg scale was reduced by the administration of 400 mg of Unifil. These results indicate that the treatment with the greater dosage administration of Unifil is effective to improve the physiological function of the respiratory system in elderly patients with COPD, and it may be the treatment of choice for elderly COPD patients.     

Noninvasive ventilation during exercise training improves exercise tolerance in patients with chronic obstructive pulmonary disease

PURPOSE: In patients with chronic obstructive pulmonary disease, pulmonary rehabilitation has been demonstrated to increase exercise capacity and reduce dyspnea. In the most disabled patients, the intensity of exercise during the training sessions is limited by ventilatory pump capacity. This study therefore evaluated the beneficial effect of noninvasive ventilation (NIV) support during the rehabilitation sessions on exercise tolerance. METHODS: This study included 14 patients with stabilized chronic obstructive pulmonary disease, ages 63 +/- 7 years, with a forced expiratory volume in 1 second (FEV(1)) 31.5% +/- 9.2% of predicted value. All 14 patients participated in an outpatient pulmonary rehabilitation program. Seven of the patients trained with NIV during the exercise sessions (NIV group), whereas the remaining seven patients breathed spontaneously (control group). Exercise tolerance was evaluated during an incremental exercise test and during constant work rate exercise at 75% of peak oxygen consumption (VO(2)) before and after the training program. RESULTS: The application of noninvasive ventilation increased exercise tolerance, reduced dyspnea, and prevented exercise-induced oxygen desaturation both before and after training. The pressure support was well tolerated by all the patients during the course of the training program. In the NIV group, training induced a greater improvement in peak VO(2) (18% vs 2%; P <.05) and a reduced ventilatory requirement for maximal exercise, as compared with the control group. The constant work rate exercise duration increased similarly in both groups (116% vs 81%, nonsignificant difference), and posttraining blood lactate was decreased at isotime (P <.05 in both groups), but not at the end of the exercise. CONCLUSION: In this pilot study, exercise training with noninvasive ventilation support was well tolerated and yielded further improvement in the increased exercise tolerance brought about by pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. This improved exercise tolerance is partly explained by a better ventilatory adaptation during exercise.     

Responsiveness of Three Instruments to Assess Self-Reported Functional Status in Patients with COPD

The study aimed to compare the responsiveness of three instruments to assess self-reported changes in functional status after exercise training in patients with COPD: Pulmonary Functional Status and Dyspnea Questionnaire –modified version (PFSDQ-M), London Chest Activity of Daily Living (LCADL) and Medical Research Council scale (MRC). Twenty-two patients (11 female, 66[62-71] years, FEV₁ 42[33-61]%predicted) participated in a 3-month high-intensity exercise program. The three instruments were applied pre- and post-program, as well as assessment of lung function, muscle strength, exercise capacity (6-minute walking test, 6MWT) and quality of life (St. George's Respiratory Questionnaire, SGRQ). SGRQ, 6MWT and quadriceps femoris, biceps and triceps brachialis strength improved significantly after the program (p < 0.05 for all). Training also yielded significant improvement in the LCADL total score and self-care, domestic and leisure domains and in the PFSDQ-M ‘change in activities’ domain, with no improvement in the MRC (p = 0.11). Calculation of effects sizes also indicated higher responsiveness in the LCADL than the other instruments. There were no significant correlations between changes in the three instruments and changes in lung function, SGRQ or 6MWT. In conclusion, PFSDQ-M's ‘change in activity’ domain and specially the LCADL (to a higher extent) showed responsiveness to detect changes in functional status after three months of high-intensity exercise training in patients with COPD, whereas the MRC scale did not. In this population, the improvement in functional status was not related with improvement in exercise capacity, lung function or quality of life.     

Validity of pedometers for measuring exercise adherence in heart failure patients

BACKGROUND: Measuring adherence to exercise is important to clinicians and researchers because inadequate adherence can adversely affect the effectiveness of an exercise program and cloud the relationship between exercise and clinical outcomes. Hence, assessment strategies for adherence to exercise, as with assessment strategies for other outcomes, must have demonstrated validity if they are to be employed with confidence. We conducted this study to determine the validity of pedometers as a measure of exercise adherence to a home-based walking program in heart failure patients. METHODS AND RESULTS: Exercise adherence was measured using pedometers in 38 patients (74% men) age 54.1 +/- 11.7 years who participated in a 12-month home-based walking program. A comparison of functional status as measured by the 6-minute walk distance and peak oxygen uptake (VO2 max) at 6 months into the exercise training program was made between 2 groups of participants who were thought to represent adherers and nonadherers: participants who demonstrated > or = 10% change in pedometer scores (n = 20) and those who showed no change in pedometer scores (n = 18) from baseline to 6 months. Patients who showed improvements in their pedometer scores over 6 months had better functional status at 6 months (6-minute walk distance 1718 +/- 46 versus 1012 +/- 25 meters, F = 5.699, P = .022; VO 2 max 17 +/- 0.7 versus 10 +/- 0.5 units, F = 7.162, P = .011) when compared with patients whose pedometers reflected minimal change in distance walked (ie, < or = 10%). CONCLUSION: Pedometers are inexpensive and readily available to both clinicians and researchers. The results of this study suggest that they may be a valid indicator of exercise adherence in heart failure patients who participate in a home-based walking program.     

Effect of inhaled anticholinergic drug on pulmonary function and quality of life in elderly patients with chronic obstructive pulmonary disease

Effects of inhaled anticholinergic drug on the physiological function of the respiratory system and quality of life (QOL) in elderly patients with chronic obstructive pulmonary disease (COPD) have not been fully elucidated. We examined the pulmonary function, static respiratory pressures, and ventilation during exercise, before and after inhalation of oxitropium bromide (OTB) in 12 male patients with COPD (mean age 82.1 +/- 0.6 years). QOL was measured with a St George's Respiratory Questionnaire (SGRQ) in the patients. Forced expiratory volume in one second was increased by the inhalation of OTB in the patients, whereas the ratio of residual volume to total lung capacity was decreased by the inhalation. Maximum inspiratory pressure was significantly increased after the administration of OTB. Dyspnea sensation during exercise measured on the Borg scale was reduced by the inhalation of OTB. The scores of SGRQ were improved by one-month treatment with OTB. These results suggest that the treatment with OTB are effective for both physiological function and several aspects of QOL in elderly patients with COPD.