Effectiveness of exercise training in patients with COPD: the role of muscle fatigue

The improvement in exercise performance in response to exercise training varies greatly from one patient with chronic obstructive pulmonary disease to another. It is possible that in a portion of patients the muscle stimulus applied during exercise training is insufficient to elicit training effects. We investigated whether patients presenting quadriceps contractile fatigue after training have more favourable effects of a rehabilitation programme. 46 patients followed a 3-month high-intensity exercise training programme. Exercise capacity, quadriceps force and quality of life were measured before and after the programme. Exercise training-induced quadriceps contractile fatigue was assessed after 1 month of rehabilitation with magnetic stimulation. A fall in quadriceps force of ≥15%, 15 min after training was considered as significant fatigue. 29 (63%) out of 46 patients developed significant fatigue. Patients with fatigue had a higher increase in 6-min walk distance (median (interquartile range) 57 (47-103) m versus 17 (-7-46) m; p=0.0023) and Chronic Respiratory Disease Questionnaire score (mean±sd 22±12 points versus 14±12 points; p=0.028) after the training programme compared with patients without fatigue. Improvements in quadriceps force and maximal exercise capacity were similar in both subgroups. Patients who develop quadriceps contractile fatigue during exercise training show greater training effects in terms of functional exercise capacity and health-related quality of life.     

Rehabilitation of patients with chronic obstructive pulmonary disease. Exercise twice a week is not sufficient!

Several studies of chronic obstructive pulmonary disease (COPD) have shown that pulmonary rehabilitation, consisting of at least three training sessions a week, improves exercise performance and health status. This study investigates feasibility, effect and economic aspects of a rehabilitation programme consisting of two sessions a week for 8 weeks. Twenty-four patients with moderate COPD were randomized to rehabilitation and 21 to placebo. Patients were assigned to an 8-week programme of exercise plus education (Exercise group) or conventional community care (Placebo group). The rehabilitation program was carried out in a hospital outpatient setting and consisted of 16 h exercise and 13.5 h of education. The exercise group received physiotherapy and education twice a week. Seven patients did not complete the programme. The characteristics of the 38 COPD-patients at baseline were the following: (mean +/- SD) forced expiratory volume in 1 sec (FEV1) 1.1+/-0.4 1 (47% of predicted), 6-min walking distance (6MWD) 413+/-75 m, score of St. George's Respiratory Questionnaire (SGRQ) 44+/-21. Health-status, assessed by SGRQ and The Psychological General Well-being (PGWB) Index, did not improve. Rehabilitation resulted in an insignificant improvement in the 6MWD [29 m (95% confidence interval: -8 -66 m)]. We conclude that a rehabilitation program consisting of exercise and education twice a week for 8 weeks had no effect on exercise performance and well being in patients with moderate COPD.     

Cardiopulmonary stress during exercise training in patients with COPD.

Exercise training is an essential component of pulmonary rehabilitation. However, the cardiopulmonary stress imposed during different modalities of exercise training is not yet known. In the present study, the cardiopulmonary stress of a 12-week exercise training programme in 11 chronic obstructive pulmonary disease (COPD) patients (forced expiratory volume in one second 42+/-12%pred, age 69+/-6 yrs) was measured. Pulmonary gas exchange and cardiac frequency (f(C)) of three training sessions were measured with a portable metabolic system at the beginning, mid-term and end of the programme. Symptoms were assessed with Borg scores. The exercise intensity was compared with the recommendations for exercise training by the American College of Sports Medicine (ACSM). Training effects were significant (maximum change in work: 14+/-11 Watts, 6-min walk test: 44+/-36 m). Whole body exercises (cycling, walking and stair climbing) consistently resulted in higher cardiopulmonary stress (oxygen uptake (V'(O(2))), minute ventilation and f(C)) than arm cranking and resistance training. Dyspnoea was higher during cycling than resistance training. Patients exercised for >70% (>20 min) of the total exercise time at >40% of the V'(O(2)) reserve and f(C) reserve ("moderate" intensity according to the ACSM) throughout the programme. The cardiopulmonary stress resistance training is lower than during whole-body exercise and results in fewer symptoms. In addition, exercise testing based on guidelines using a fixed percentage of baseline peak performance and symptom scores achieves and sustains training intensities recommended according to the American College of Sports Medicine.     

Pulmonary rehabilitation for COPD: are programs with minimal exercise equipment effective?

Pulmonary rehabilitation is an essential component of chronic obstructive pulmonary disease (COPD) management with strong evidence supporting the efficacy of pulmonary rehabilitation to improve exercise capacity and quality of life, as well as reduce hospital admissions. However, it is estimated that only 2-5% of people with COPD who could benefit from pulmonary rehabilitation have access to programs. Most research on the benefits of pulmonary rehabilitation has used equipment such as cycle ergometers and treadmills for endurance training and weight machines for resistance training. To enable greater availability of pulmonary rehabilitation, the efficacy of exercise training using minimal equipment needs to be evaluated. Randomised controlled trials that used minimal, low cost equipment for endurance (eight trials) and strength training (three trials) compared to no training in people with COPD were evaluated. Statistically and clinically significant differences in functional exercise capacity and quality of life, as well as improvements in strength were demonstrated when exercise training with minimal equipment was compared to no training [six-minute walk test: mean difference 40 (95% CI: 13 to 67) metres; St George’s Respiratory Questionnaire: mean difference -7 (95% CI: -12 to -3) points]. While the number of studies is relatively small and of variable quality, there is growing evidence that exercise training using minimal, low cost equipment may be an alternative to equipment-intensive pulmonary rehabilitation programs.     

Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation

The principals of rehabilitation medicine are to prevent muscle atrophy and improve mobility. Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with muscle atrophy and yet many patients do not undergo pulmonary rehabilitation until they have been in stable health for some time. We investigated the outcome of a supervised home exercise programme initiated immediately after hospitalisation for an exacerbation of COPD. Thirty-one patients were randomised into an exercise group (n=16, FEV(1) 0.94+/-0.34 L) and a control group (n=15, FEV(1) 1.08+/-0.33 L). The exercise group received a twice-weekly supervised exercise programme, in their homes, for 6 weeks. Spirometry, exercise capacity, isometric muscle strength, dyspnea level, quality of life at baseline and 6 weeks as well as subsequent exacerbations were quantified. At 6 weeks, the exercise group, improved the shuttle walk test (198 m+/-95-304+/-136 m) and increased 3 min step test capacity (119+/-40-163+/-26s) (both P<0.001). Knee extensor muscle strength and quality of life scores also increased. Neither exercise capacity nor muscle strength altered in the control group. Follow-up at 3 months showed that three of the control group and none of the exercise group had experienced subsequent exacerbations (P=0.06). Early rehabilitation via a home from hospital programme improved exercise tolerance, muscle strength, dyspnea scores, quality of life in COPD patients and reduced the number of subsequent exacerbations.     

Developing the model of pulmonary rehabilitation for chronic heart failure

Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) commonly suffer from exertional symptoms of breathlessness and fatigue. The similar systemic manifestations of the conditions, including skeletal muscle dysfunction, are a major contributing factor to the limitation in exercise capacity. A period of exercise training has been shown to improve exercise performance and health-related quality of life for both conditions. Exercise training is a key component of pulmonary rehabilitation (PR) which is now a standard of care for patients with COPD and is symptom based. Although it may be assumed that patients with CHF could be incorporated into cardiac rehabilitation, this is predominantly a secondary prevention programme for patients who are largely asymptomatic. It has been shown that patients with CHF can be successfully trained together with patients with COPD by the same therapists within PR. There are comparable outcome measures that can be used for both COPD and CHF. Many patients with CHF still do not have access to an exercise rehabilitation programme and incorporating them into the PR model of care could be one solution. This article reviews the (1) similar symptoms, mechanisms and consequences between COPD and CHF, (2) rationale and evidence for exercise training in CHF, (3) model of PR, (4) safety of exercise training in CHF, (5) evidence for combined exercise rehabilitation for CHF and COPD, (6) adaptations necessary to include patients with CHF into PR, (7) the chronic care model and (8) summary.     

High versus low intensity exercise training in pulmonary rehabilitation: is more better?

BACKGROUND: Exercise training is considered a necessary component of comprehensive pulmonary rehabilitation. However, to date, there is no consensus on an exercise training strategy for pulmonary rehabilitation, and this has resulted in varied approaches to this intervention in its literature. As in healthy individuals, the effect of exercise training on patients with chronic lung disease is dose dependent, with higher intensities resulting in greater physiological adaptations than lower intensities. RESULTS: It is not clear from our review of the literature that these enhanced physiological effects from higher levels of exercise training translate into a reduced burden of symptoms, hence a better quality of life. Indeed, there is some evidence that pulmonary rehabilitation approaches incorporating lower intensities of exercise training are at least as good in improving questionnaire rated symptoms of health status. This provides food for thought, since the prominent goal of pulmonary rehabilitation should be to reduce bothersome symptoms or enhance health status, not simply increase endurance time on a cycle ergometer.     

Effects of high-intensity exercise training in a pulmonary rehabilitation programme for patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVES: The benefits of pulmonary rehabilitation for patients with COPD depend on the intensity of training. Traditional pulmonary rehabilitation programmes (PRPs) do not consistently achieve high-intensity training and have variable training effects. This study examined the effects of high-intensity exercise training on cardiac and pulmonary function in COPD patients. METHODS: Patients with COPD participated in a 6-week, cardiopulmonary exercise test-based PRP. Spirometry, 6-min walking distance and cardiopulmonary exercise test were used to evaluate cardiopulmonary function, respiratory muscle strength and endurance at rest, during exercise and before and after the programme. Patients were encouraged to complete high-intensity exercise with a targeted training intensity of at least 75% maximum oxygen uptake (VO(2)). RESULTS: Thirty-four COPD patients were enrolled into the study; 16 completed the high-intensity training, 18 did not. At the end of the 12-session PRP, submaximal exercise capacity (6-min walking distance, 461.8 +/- 77.2-502.7 +/- 66.9 m, P < 0.001) improved in both the patients who completed high-intensity training and those who did not. Only the patients who completed high-intensity training had significant improvements in FVC (2.47 +/- 0.70-2.70 +/- 0.62 L, P = 0.024) at rest, maximal exercise capacity (peak VO(2), 1001.6 +/- 286.4-1116.1 +/- 320.4 mL/min, P = 0.020) and work efficiency (7.3 +/- 1.4-8.4 +/- 1.8 mL/min/watt, P = 0.026). There was no statistically significant difference between the two groups in the change in the physiological parameters before and after exercise. CONCLUSIONS: Exercise training in a PRP improved submaximal exercise capacity. Only patients who completed high-intensity exercise training showed improvements in maximal exercise capacity, FVC and work efficiency.     

Inspiratory muscle training in patients with chronic obstructive pulmonary disease

To investigate the effects of inspiratory muscle resistive loading training (IMT) on exercise performance in chronic obstructive pulmonary disease (COPD), 13 patients undergoing standard pulmonary rehabilitation were divided into control (n = 6) and experimental (n = 7) groups. Prior to training, we measured inspiratory muscle strength and endurance, resting pulmonary function, and exercise performance on a bicycle ergometer (a progressive test and an endurance test at two thirds of maximal work load). We then determined their resistive loads for training by measuring their 10-min maximal sustainable resistance. Training by patients in the experimental group involved inspiring against a predetermined resistive load. The control subjects breathed through a sham training tube, so that studies were performed in double-blind fashion. The training consisted of 15-min sessions twice daily for 4 wk. The IMT dramatically improved inspiratory muscle endurance--represented as either sustainable inspiratory pressure (SIP) or endurance time at 60% of maximal inspiratory mouth pressure (Pimmax) at functional residual capacity. The SIP of the trained group increased from 29 +/- 11 to 46 +/- 11% of Pimmax (p less than 0.005). Training slightly increased inspiratory muscle strength (p less than 0.05), as determined by Pimmax. In contrast, resting pulmonary function and performance of both progressive and constant-load exercise remained unchanged. We conclude that 4-wk IMT in a pulmonary rehabilitation setting improves inspiratory muscle endurance in patients with COPD without changing pulmonary function or exercise performance.     

Indications and results of exercise rehabilitation in patients with chronic obstructive lung diseases]

The aim of physical exercise retraining in patients with chronic obstructive lung disease undergoing rehabilitation is to increase the anaerobic work capacity with a rise in VO2 max. Exercise programmes must take into account the duration, frequency and intensity of exercise. In these patients, numerous factors limit physical exercise, including (a) decreased ventilatory capacity and respiratory muscles fatigue; (b) decreased efficacy of the pulmonary gas exchanges; (c) altered pulmonary vascular bed with altered cardiovascular response. The most widely used training methods are walking (or running), practising on a conveyor belt and using an ergometric bicycle. The last named seems to be the best method to evaluate the physiological effects of exercise or for experimental studies. Patients who are fit to participate in a retraining programme must be in a stable period and have a stable pharmacological regimen; they must be subjected to a preliminary exercise test in order to evaluate the main physiological parameters and to obtain information on their tolerance to exercise, on the presence of lactic acidosis and on the degree of hypoxaemia and hypercapnia. In the absence of contra-indications, a training programme can be set up with 30 to 45 minutes of exercise per day at least 3 to 5 times a week during 5 to 8 weeks, with a load amounting to 50-60% of VO2 max. Two questions remain to be answered: (a) is oxygen therapy useful during retraining; (b) what effect has training on survival?     

Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis.

The purpose of this meta-analysis is to review studies investigating the efficacy of inspiratory muscle training (IMT) in chronic obstructive pulmonary disease (COPD) patients and to find out whether patient characteristics influence the efficacy of IMT. A systematic literature search was performed using the Medline and Embase databases. On the basis of a methodological framework, a critical review was performed and summary effect-sizes were calculated by applying fixed and random effects models. Both IMT alone and IMT as adjunct to general exercise reconditioning significantly increased inspiratory muscle strength and endurance. A significant effect was found for dyspnoea at rest and during exercise. Improved functional exercise capacity tended to be an additional effect of IMT alone and as an adjunct to general exercise reconditioning, but this trend did not reach statistical significance. No significant correlations were found for training effects with patient characteristics. However, subgroup analysis in IMT plus exercise training revealed that patients with inspiratory muscle weakness improved significantly more compared to patients without inspiratory muscle weakness. From this review it is concluded that inspiratory muscle training is an important addition to a pulmonary rehabilitation programme directed at chronic obstructive pulmonary disease patients with inspiratory muscle weakness. The effect on exercise performance is still to be determined.     

Strength training in patients after myocardial infarct

The objective of the work was to evaluate the suitability and safety of resistance training in patients after myocardial infarction (IM), in older patients and to assess the suitable time for including resistance exercise into the rehabilitation programme. The group comprises a total of 74 patients after IM aged 27-76 years (57 +/- 9). The group included 65 men and 9 women. The authors divided the whole group into two sub-groups by age. The first group is formed by patients under 65 years and the second one by those aged > 65 years. The authors included resistance training from the third week of the rehabilitation programme. During the resistance exercise none of the patients suffered from impaired rhythm or stenocardia. The total muscular strength during the initial tests was in the first group (< 65 years) 105 +/- 26 kg and 93 +/- 26 kg in the group of older patients. At the end of the rehabilitation programme in both groups a statistically significant increase of the total strength was recorded. In the first group it was 120 +/- 20 kg and in the older patients 108 +/- 23 kg, i.e. an increase by 14 and 16%. The mean value of the ejection fraction (EF) was at the onset of rehabilitation 58 +/- 7% and did not differ substantially in the two groups. The mean EF value at the end of rehabilitation was 59 +/- 9% in the first group and 58 +/- 10% in the second group (n.s.). The body weight expressed as the body mass index was initially significantly lower in the older patients (25.5 +/- 2.6 kg/m2 vs. 27.4 +/- 3.3 kg/m2, p < 0.01). During the rehabilitation programme in both groups a slight but statistically significant decline of body weight was recorded. In the first group (< 65 years) to 27.0 +/- 3.2 kg/m2 and in the group of older patients to 25.2 +/- 2.4 kg/m2 (p < 0.01). It can be concluded that the application of resistance exercise as a supplement of classical aerobic training is a suitable, beneficial and safe extension of the regabilitation programme. The use of resistance exercise is suitable even in older patients, it is well tolerated and is not associated with cardiovascular complications. Resistance exercise can be applied already after two weeks of the aerobic programme.     

New strategies to improve exercise tolerance in chronic obstructive pulmonary disease.

Breathlessness is the most common symptom limiting exercise in patients with chronic obstructive pulmonary disease (COPD). Exercise training can improve both exercise tolerance and health status in these patients, intensity being of key importance. Nevertheless, in these patients extreme breathlessness and/or peripheral muscle fatigue may prevent patients from higher levels of intensity. In this review article the literature concerning the different ways to optimise exercise tolerance in patients with COPD, with the objective of enhancing the tolerance to higher exercise training intensity, is summarised. Continuous positive airway pressure and different modalities of noninvasive positive pressure ventilation (NPPV) may reduce breathlessness and increase exercise tolerance in these patients. Respiratory muscle unloading and reduction in intrinsic positive end-expiratory pressure have been considered among mechanisms underlying these effects. Nevertheless, the role of NPPV in pulmonary rehabilitation, if any, is still controversial. The addition of nocturnal domiciliary NPPV during a daily exercise programme in patients with severe COPD resulted in an improvement in exercise tolerance and quality of life. In patients with severe COPD application of electrical stimulation combined with active limb mobilisation significantly improved muscle strength, and interval training has been shown capable of inducing physiological training effects. Oxygen supplementation in patients who do not desaturate during exercise seems to be the most promising treatment, since it allows for higher exercise intensities and, therefore, superior training efficacy. In conclusion, further studies are needed to define the appropriate patients in order to generalise such interventions. The modalities discussed should be used as adjuncts to a well designed comprehensive respiratory rehabilitation programme.     

Effects of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis

Background and objective:   Although pulmonary rehabilitation is effective for patients with COPD, its efficacy in patients with IPF is unknown. The purpose of this study was to evaluate the effects of pulmonary rehabilitation in IPF.
Methods:   Thirty patients diagnosed with IPF, according to the consensus statement, were randomly assigned to the rehabilitation group or the control group. The pulmonary rehabilitation mainly consisted of a 10-week programme of exercise training. Pulmonary function, blood gas analysis, 6MWD, dyspnoea rating with the baseline dyspnoea index and health-related quality of life score on the St George's Respiratory Questionnaire were evaluated at baseline and after the programme.
Results:   Assessment of efficacy was carried out on 13 patients who completed the programme and 15 patients in the control group. There were no significant effects of the programme on measures of pulmonary function, values of arterial blood gas analysis or dyspnoea rating. Although there were some differences in the baseline 6MWD and total health-related quality of life score which were not statistically significant, marked improvements were observed in the 6MWD (mean difference 46.3 m (95% CI: 8.3–84.4), P  < 0.05) and the total health-related quality of life score (−6.1 (95% CI: −11.7 to −0.5), P  < 0.05).
Conclusions:   Pulmonary rehabilitation improves both exercise capacity and health-related quality of life in patients with IPF.     

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.     

Perioperative Short-term Pulmonary Rehabilitation for Patients Undergoing Lung Volume Reduction Surgery

Although pulmonary rehabilitation is recommended for patients undergoing lung volume reduction surgery, the optimal method of pulmonary rehabilitation is unclear. The aim of this study was to determine the feasibility and safety of perioperative short-term pulmonary rehabilitation. We enrolled candidates for lung volume reduction surgery from 1999 to 2006 and retrospectively evaluated the feasibility and safety of perioperative short-term pulmonary rehabilitation for these patients. The program included the progressive exercise training on a treadmill for approximately 3 weeks. Two primary endpoints, feasibility and safety, were determined by the adherence rates of the program session and the adverse events. Pulmonary function and exercise capacity were evaluated at baseline and the termination of pre- and postoperative short-term pulmonary rehabilitation. Twenty-two patients were enrolled in this study. All patients completed our program without any serious adverse events. The mean values of adherence rates of the preoperative, postoperative, and overall period were, 89.1%, 95.1%, and 92.1%, respectively. All values of pulmonary function tests, except for forced vital capacity, significantly improved at the termination of postoperative short-term pulmonary rehabilitation in comparison to those at the termination of preoperative short-term pulmonary rehabilitation. The values of the 6-minute walk distance, total exercise time, and maximal workload on incremental exercise test were significantly improved by preoperative short-term pulmonary rehabilitation, and their values were maintained until the termination of postoperative short-term pulmonary rehabilitation. The results indicated that it is both feasible and safe to perform perioperative short-term pulmonary rehabilitation.     

Perioperative short-term pulmonary rehabilitation for patients undergoing lung volume reduction surgery

Although pulmonary rehabilitation is recommended for patients undergoing lung volume reduction surgery, the optimal method of pulmonary rehabilitation is unclear. The aim of this study was to determine the feasibility and safety of perioperative short-term pulmonary rehabilitation. We enrolled candidates for lung volume reduction surgery from 1999 to 2006 and retrospectively evaluated the feasibility and safety of perioperative short-term pulmonary rehabilitation for these patients. The program included the progressive exercise training on a treadmill for approximately 3 weeks. Two primary endpoints, feasibility and safety, were determined by the adherence rates of the program session and the adverse events. Pulmonary function and exercise capacity were evaluated at baseline and the termination of pre- and postoperative short-term pulmonary rehabilitation. Twenty-two patients were enrolled in this study. All patients completed our program without any serious adverse events. The mean values of adherence rates of the preoperative, postoperative, and overall period were, 89.1%, 95.1%, and 92.1%, respectively. All values of pulmonary function tests, except for forced vital capacity, significantly improved at the termination of postoperative short-term pulmonary rehabilitation in comparison to those at the termination of preoperative short-term pulmonary rehabilitation. The values of the 6-minute walk distance, total exercise time, and maximal workload on incremental exercise test were significantly improved by preoperative short-term pulmonary rehabilitation, and their values were maintained until the termination of postoperative short-term pulmonary rehabilitation. The results indicated that it is both feasible and safe to perform perioperative short-term pulmonary rehabilitation.     

Effect of physical training on the magnitude of left ventricular ischaemic dysfunction in patients with chronic ischaemic heart disease

Twenty-two patients with chronic ischaemic heart disease (IHD) and reversible myocardial ischaemia after a load as recorded by single photon emission computed tomography (SPECT) participated in an eight-week rehabilitation programme. Before exercise their efficiency was tested by spiroergometric examinatin and the patients were randomized into two groups. Group A (10 patients) took exercise at the level of the anaerobic threshold (high intensity training), group B (12 patients) trained at the level of the 60 % anaerobic threshold (low intensity training). The exercise unit including the warming up and relaxation stage lasted 50 minutes and was repeated three times per week. Before and after the rehabilitation programme in all patients spiroergometry was performed as well as exercise pulsed tissue Doppler echocardiography to evaluate regional systolic and diastolic left ventricular function in the ischaemic area, localized beforehand by the SPECT. The following parameters were evaluated by echocardiograpphy: the peak velocity of motion in the ischaemic area in systole (Si), the peak velocity of motion in the ischaemic area in early diastole (Ei) ad in atrial contraction (Ai), and the ratio Ei/Ai was calculated. With the exception of the decline of the value at rest Ai from 8.4 +/- 1.3 cm/sec to 7.3 +/- 1.3 cm/s (p < 005) in the exercising group A none of the parameters of left ventricular regional function changed significantly after an eight-week rehabilitation programme. The maximal performance achieved in spiroergometry increased however after rehabilitation in group A (from 145 +/- 36 W to 162 +/- 39 W, p < 0.01) as well as in group B (from 112 +/- 36W to 122 +/- 36W, p < 0.05). I It may be concluded that a rehabilitation programme of high and low intensity improved the load tolerance during spiroergometry but did not lead to significant improvement of regional systolic and diastolc left ventricular function in the area of reversible ischaemia.     

Improvements in outcomes for chronic obstructive pulmonary disease (COPD) attributable to a hospital-based respiratory rehabilitation programme

Aim: To determine whether the benefits of pulmonary rehabilitation, demonstrated in selected subjects in randomised controlled studies, can be achieved by a hospital-based respiratory rehabilitation programme conducted as part of routine clinical management. Methods: Design: A prospective longitudinal study of patients with severe chronic obstructive pulmonary disease (COPD) enrolled in a hospital based, non-medically supervised, outpatient, respiratory rehabilitation programme was undertaken. The rehabilitation programme was of pragmatic design and content, supervised by respiratory physiotherapists and comprised seven two hour sessions over one month for groups of six to eight patients. It included education on disease management, practical instruction in coping skills, as well as a progressive aerobic exercise programme for specific muscle training related to functional activities. Subjects were assessed prior to the programme but after optimisation of pharmacologic therapy, at the completion of the programme and at three months and six months post-programme. Principal outcome parameters were exercise capacity (as assessed by a six minute walk distance [MWD] test), degree of perceived breathlessness and quality of life (QOL) (assessed by the Chronic Respiratory Disease Questionnaire [CRDQ]). Results: Fifty-one subjects with severe COPD (Fev₁=0.9±0.4 1) completed the programme. There was a significant improvement in exercise capacity (a six MWD test improved from 375±126 m at baseline to 440±109 m at three months, p<0.005). There were significant improvements in QOL (in the total CRDQ score as well as in the domains of dyspnoea, fatigue and mastery). There was a reduction in the level of perceived dyspnoea (modified Borg Scale). Most improvements were maintained for three and six months following completion of the programme. Compared with the six months preceding the programme there was a reduction in hospital admissions and reduction in courses of oral steroids. Conclusions: An outpatient, hospital-based respiratory rehabilitation programme pragmatically adapted for clinical utility produces substantial and clinically significant improvements in exercise tolerance and QOL, similar in type and magnitude to those obtained in controlled clinical trials. There was an associated reduction in COPD-related morbidity. Such gains were mostly maintained for six months after completion of the programme. Thus respiratory rehabilitation must be regarded as an essential component of a comprehensive clinical programme for the management of COPD.