Exercise in chronic pulmonary disease: resistance exercise prescription

The effects of inspiratory muscle warm-up prior to inspiratory muscle training during pulmonary rehabilitation in subjects with chronic obstructive pulmonary disease: a randomized trial

BACKGROUND

While a whole-body warm-up may not adequately prepare the inspiratory muscles for exercise, inspiratory warm-up is an effective approach in preparing the inspiratory muscles for exertion.

OBJECTIVES

To investigate the effects of inspiratory muscle warm-up performed prior to inspiratory muscle training (IMT) during pulmonary rehabilitation (PR) in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) and inspiratory muscle weakness.

METHODS

Pulmonary function tests, maximal inspiratory and expiratory pressures (MIP and MEP), 6-minute walk test distance (6MWD), modified Medical Research Council Dyspnea Scale(mMRC), St. George's respiratory questionnaire and the 36-item short-form health survey were evaluated. Both groups performed IMT during PR for 8 weeks. The warm-up group (n = 15), in addition to the standard IMT group (n = 15), performed an inspiratory muscle warm-up protocol before each IMT session.

RESULTS

At the end of the 8-week intervention, improvements in dyspnea (mMRC in score, p =0.033, effect size =0.76); exercise capacity (6MWD in meters, p =0.001, effect size =1.30); pulmonary function [forced expiratory volume in 1 second (FEV1) in %predicted, p =0.006, effect size =1.10]; and inspiratory muscle strength (MIP in cmH2O, p =0.001, effect siz e = 1.35) were significantly greater in the warm-up group. Moreover, there were significant improvements in health-related quality of life (HRQoL) sub-scores after the training in both groups (p <0.05).

CONCLUSIONS

This study demonstrated improvements in both groups, surpassing or closely approaching the established minimal clinically important difference values for the respective outcomes. Performing a warm-up for inspiratory muscles before IMT boosts benefits for pulmonary function, inspiratory muscle strength, exercise capacity, dyspnea, and HRQoL in subjects with moderate-to-severe COPD and inspiratory muscle weakness.

Influence of home-based pulmonary rehabilitation program among people with interstitial lung disease: A pre-post study

INTRODUCTION

Access to interstitial lung disease programs may not be available in rural settings. Home-based pulmonary rehabilitation (PR) programs have been proposed as an alternative to hospital-based programs.

METHOD

Forty participants with ILD underwent a structured unsupervised home-based pulmonary rehabilitation program from September 2020 to September 2022. Quality of life was assessed using St. George Respiratory Questionnaire (SGRQ) and functional capacity using 6-minute walk test (6MWT). The outcome measures were assessed at baseline and 4 weeks post-unsupervised home-based PR program.

RESULT

We recruited 40 participants with ILD. There was statistically significant improvement in the 6-minute walk distance (353.8 m and 368 m, effect size - 0.5, p ≤ .001) and quality of life using SGRQ total score (38.6 and 42.35, effect size - 2.5, p ≤ .001) between before and after receiving home-based PR among all 40 participants with ILD.

CONCLUSION

Four weeks of home-based PR program, using minimal resources, deliver short-term improvements in functional exercise capacity and quality of life among ILD participants. Our home-based PR program resulted in a quarter percentage improvement in functional capacity, and we believe that if consistency is maintained, it will result in similar changes corresponding to the already established Minimal Clinically Important Difference (MCID) of 35 m.

Dancing for Health and Wellbeing: A Feasibility Study of Examining Health Impacts of Online Dancing among Pulmonary Fibrosis Patients

BACKGROUND

Physical activity (PA) is recommended in the management of patients with pulmonary fibrosis (PF) to improve health outcomes. Dance is one such form of PA which is meaningful, valuable, enjoyable and has demonstrated positive physical and mental health effects.

METHODS

With pre-post design, 16 patients, members of the Irish Lung Fibrosis Association, were enrolled in this study. Once weekly, 75-min dance sessions were delivered for eight weeks via Zoom by an experienced choreographer. Participants completed Chronic Respiratory Questionnaire Self-Administered Standardised Format (CRQ-SAS) and European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) to assess self-rated quality of life. A paired-sample t-test was employed to assess the mean differences between the pre-and post-intervention scores.

RESULTS

Most patients (78.57%) were aged over 60 years; with 71.43% diagnosed with pulmonary fibrosis more than 3 years ago. We performed an analysis of 10/16 participants who completed the intervention (5 males, 5 females). On CRQ-SAS scale we found, (a) dyspnoea-small to moderate magnitude improvement of 0.5-1.0 among 50%, (b) fatigue-small to moderate magnitude improvement of 0.5-1.0 among 40%, (c) emotional function-small to high magnitude improvement of 0.5-2.0 among 50%, (d) mastery-small magnitude improvement of 0.5 among 20%. Participants reported their health moderate to best on Visual Analogue Scale of EQ-5D-3L which improved by 1-3 scale among 40%. Mental health improved as percentage of not feeling anxious or depressed rose post event from 42.86% to 72.73%.

CONCLUSION

Our findings demonstrate that a virtual dance intervention is acceptable, enjoyable and feasible for improving health outcomes among PF patients. More organised and continuous events in future may reveal cost-benefit ratio and impact on health outcomes.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

Combined aerobic and resistance training improves respiratory and exercise outcomes more than aerobic training in adolescents with idiopathic scoliosis: a randomised trial

QUESTION

In adolescents with idiopathic scoliosis, does combined aerobic and resistance training improve respiratory function, perceived exertion and functional exercise capacity more than aerobic training only?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

Forty adolescents with idiopathic scoliosis and formal indication for surgical correction (spinal curvature ≥ 45 deg).

INTERVENTION

Both groups undertook three 60-minute training sessions per week for 12 weeks. The experimental group performed combined aerobic and resistance training and the control group performed only aerobic training.

OUTCOME MEASURES

At baseline and upon completion of treatment, participants completed: a 6-minute walk test with Borg scale (0 to 10) rating of exertion, spirometry, maximal respiratory pressures and peak expiratory flow measurement.

RESULTS

After 12 weeks of training, the experimental group improved more than the control group on the 6-minute walk test (MD 22 m, 95% CI 4 to 40), with lower perceived exertion at the end of the test (MD -1.2, 95% CI -1.9 to -0.4). The experimental group also improved more than the control group on several respiratory measures, including: FEV₁ (MD 270 ml, 95% CI 30 to 510), maximal inspiratory pressure (MD 4 cmH₂O, 95% CI 1 to 8) and peak expiratory flow (MD 33 l/minute, 95% CI 7 to 58).

CONCLUSION

In adolescents with idiopathic scoliosis, combined aerobic and resistance training improves functional exercise capacity and several respiratory outcomes more than a similar training regimen with aerobic training only. It is unclear whether the magnitude of the benefits is large enough to be worthwhile.

TRIAL REGISTRATION

NCT02413788.

PUREAIR protocol: randomized controlled trial of intensive pulmonary rehabilitation versus standard care in patients undergoing surgical resection for lung cancer

Background

Non-small cell lung cancer is the most common type of lung cancer. Surgery is proven to be the most effective treatment in early stages, despite its potential impact on quality of life. Pulmonary rehabilitation, either before or after surgery, is associated with reduced morbidity related symptoms and improved exercise capacity, lung function and quality of life.

Methods

We describe the study protocol for the open-label randomized controlled trial we are conducting on patients affected by primary lung cancer (stages I-II) eligible for surgical treatment. The control group receives standard care consisting in one educational session before surgery and early inpatient postoperative physiotherapy. The treatment group receives, in addition to standard care, intensive rehabilitation involving 14 preoperative sessions (6 outpatient and 8 home-based) and 39 postoperative sessions (15 outpatient and 24 home-based) with aerobic, resistance and respiratory training, as well as scar massage and group bodyweight exercise training.

Assessments are performed at baseline, the day before surgery and one month and six months after surgery. The main outcome is the long-term exercise capacity measured with the Six-Minute Walk Test; short-term exercise capacity, lung function, postoperative morbidity, length of hospital stay, quality of life (Short Form 12), mood disturbances (Hospital Anxiety and Depression Scale) and pain (Numeric Rating Scale) are also recorded and analysed. Patient compliance and treatment-related side effects are also collected. Statistical analyses will be performed according to the intention-to-treat approach. T-test for independent samples will be used for continuous variables after assessment of normality of distribution. Chi-square test will be used for categorical variables. Expecting a 10% dropout rate, assuming α of 5% and power of 80%, we planned to enrol 140 patients to demonstrate a statistically significant difference of 25 m at Six-Minute Walk Test.

Discussion

Pulmonary Resection and Intensive Rehabilitation study (PuReAIR) will contribute significantly in investigating the effects of perioperative rehabilitation on exercise capacity, symptoms, lung function and long-term outcomes in surgically treated lung cancer patients. This study protocol will facilitate interpretation of future results and wide application of evidence-based practice.

Trial registration

ClinicalTrials.gov Registry n. NCT02405273 [31.03.2015].

Effectiveness of neuromuscular electrical stimulation for the rehabilitation of moderate-to-severe COPD: a meta-analysis

PURPOSE

Patients with COPD often experience skeletal muscle dysfunction. For those who are unable or unwilling to undertake physical training, neuromuscular electrical stimulation (NMES) may provide an alternative method of rehabilitation. The purpose of this meta-analysis was to investigate the controversial topic of whether this therapy is effective in patients with moderate-to-severe COPD.

PATIENTS AND METHODS

We pooled data from nine trials published between January 9, 2002 and January 4, 2016 across PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, and relevant websites for randomized controlled trials. In these trials, patients with moderate-to-severe COPD were randomly allocated to receive NMES. Primary outcomes were quadricep strength and exercise capacity. The secondary outcome was health-related quality of life.

RESULTS

We extracted data from 276 patients. NMES contributed to statistically improved quadricep strength (standardized mean difference 1.12, 95% confidence interval [CI] 0.64-1.59, I²=54%; P<0.00001) and exercise capacity, including longer exercise distance (weighted mean difference 51.53, 95% CI 20.13-82.93, I²=90%; P=0.001), and longer exercise endurance (standardized mean difference 1.11, 95% CI 0.14-2.08, I²=85%; P=0.02). There was no significant difference in St George's Respiratory Questionnaire scores (weighted mean difference -0.07, 95% CI -2.44 to 2.30, I²=56%; P=0.95).

CONCLUSION

NMES appears an effectual means of enhancing quadricep strength and exercise capacity in moderate-to-severe COPD patients. Further research is demanded to clarify its effect on other outcomes and determine the optimal parameters for an NMES program.

Qualitative outcomes of progressive resistance exercise for people with COPD

The outcomes of quantitative investigations examining the effectiveness of exercise interventions for people with COPD are limited by the small number of measurement tools that can be included. In contrast, qualitative inquiry allows broader exploration of the perceived outcomes of an intervention. The purpose of this investigation is to explore the qualitative outcomes of a progressive resistance exercise (PRE) program for people with COPD. People with COPD, enrolled in a randomized controlled trial of PRE, were invited to participate in two semi-structured interviews conducted at the end (12 weeks) and 12 weeks after the training intervention (24 weeks). Interviews were audiotaped, transcribed and then coded independently by two researchers. Themes relating to training outcomes were then developed and described. Twenty-two participants were interviewed at 12 weeks, and 19 participants at 24 weeks. After PRE, participants reported a range of physical gains, particularly with regard to improved strength and reduced breathlessness during daily activities. Improved control and confidence during activities of daily living were important psychological benefits perceived by people with COPD, as was the social support experienced during group training sessions. At 24 weeks, confidence persisted despite a perceived plateau or dissipation of physical gains. People with COPD reported physical, psychological and social benefits after PRE, which had a positive effect on activity performance. Although the perceived physical benefits of training were not prominent at 24 weeks, feelings of increased confidence and control persisted. Chronic Respiratory Disease 2007 ;4: 135—142

Pulmonary rehabilitation in lymphangioleiomyomatosis: a controlled clinical trial

Lymphangioleiomyomatosis (LAM) is a cystic lung disease frequently associated with reduced exercise capacity. The aim of this study was to assess safety and efficacy of pulmonary rehabilitation in LAM.This controlled clinical trial included 40 patients with LAM and a low physical activity level. The pulmonary rehabilitation programme comprised 24 aerobic and muscle strength training sessions and education. The primary outcome was exercise capacity (endurance time during a constant work rate exercise test). Secondary outcomes included health-related quality of life (St George's Respiratory Questionnaire (SGRQ)), 6-min walking distance (6MWD), dyspnoea, peak oxygen consumption (V'O2 ), daily physical activity (pedometer), symptoms of anxiety and depression, lung function and peripheral muscle strength (one-repetition maximum).The baseline characteristics were well balanced between the groups. The pulmonary rehabilitation group exhibited improvements in the following outcomes versus controls: endurance time (median (interquartile range) 169 (2-303) s versus -33 (-129-39) s; p=0.001), SGRQ (median (interquartile range) -8 (-16-2) versus 2 (-4-5); p=0.002) and 6MWD (median (interquartile range) 59 (13-81) m versus 20 (-12-30) m; p=0.002). Dyspnoea, peak V'O2 , daily physical activity and muscle strength also improved significantly. No serious adverse events were observed.Pulmonary rehabilitation is a safe intervention and improves exercise capacity, dyspnoea, daily physical activity, quality of life and muscle strength in LAM.

The benefits of exercise training in interstitial lung disease: protocol for a multicentre randomised controlled trial

Background

Interstitial lung disease encompasses a diverse group of chronic lung conditions characterised by distressing dyspnoea, fatigue, reduced exercise tolerance and poor health-related quality of life. Exercise training is one of the few treatments to induce positive changes in exercise tolerance and symptoms, however there is marked variability in response. The aetiology and severity of interstitial lung disease may influence the response to treatment. The aims of this project are to establish the impact of exercise training across the range of disease severity and to identify whether there is an optimal time for patients with interstitial lung disease to receive exercise training.

Methods/Design

One hundred and sixteen participants with interstitial lung disease recruited from three tertiary institutions will be randomised to either an exercise training group (supervised exercise training twice weekly for eight weeks) or a usual care group (weekly telephone support). The 6-minute walk distance, peripheral muscle strength, health-related quality of life, dyspnoea, anxiety and depression will be measured by a blinded assessor at baseline, immediately following the intervention and at six months following the intervention. The primary outcome will be change in 6-minute walk distance following the intervention, with planned subgroup analyses for participants with idiopathic pulmonary fibrosis, dust-related interstitial lung disease and connective-tissue related interstitial lung disease. The effects of disease severity on outcomes will be evaluated using important markers of disease severity and survival, such as forced vital capacity, carbon monoxide transfer factor and pulmonary hypertension.

Discussion

This trial will provide certainty regarding the role of exercise training in interstitial lung disease and will identify at what time point within the disease process this treatment is most effective. The results from this study will inform and optimise the clinical management of people with interstitial lung disease.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12611000416998

State of the art: how to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health-related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost-effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.

Influência do treinamento da musculatura respiratória e de membros inferiores no desempenho funcional de indivíduos com DPOC

A doença pulmonar obstrutiva crônica (DPOC) caracteriza-se pela obstrução ou limitação crônica do fluxo aéreo, gerando uma desvantagem mecânica, causando fraqueza muscular e recrutamento da musculatura inspiratória acessória. A disfunção muscular esquelética é uma importante manifestação extrapulmonar, que leva à diminuição da capacidade funcional. O objetivo do estudo foi verificar a eficácia de um treinamento da musculatura respiratória e de quadríceps no desempenho funcional de indivíduos com DPOC. De nove indivíduos com idades entre 49 e 76 anos foram avaliadas as pressões respiratórias máximas (por manovacuometria), força muscular de membros inferiores (por repetição máxima), capacidade funcional (pelo teste de caminhada com carga progressiva, shuttle test) e qualidade de vida (pelo questionário de qualidade de vida SF-36), antes e depois da aplicação de protocolo de fortalecimento da musculatura inspiratória, dos músculos quadríceps e abdominais. As sessões de exercícios foram realizadas duas vezes por semana durante dois meses. Foi verificada melhora em todas as variáveis avaliadas, com diferença significativa na pressão inspiratória máxima (p<0,05). O treinamento da musculatura respiratória e de quadríceps proposto mostrou-se benéfico ao desempenho funcional de indivíduos com DPOC, sugerindo a utilização do fortalecimento muscular respiratório e periférico como recurso coadjuvante no tratamento desses indivíduos.

Position stand on androgen and human growth hormone use

Hoffman, JR, Kraemer, WJ, Bhasin, S, Storer, T, Ratamess, NA, Haff, GG, Willoughby, DS, and Rogol, AD. Position stand on Androgen and human growth hormone use. J Strength Cond Res 23(5): S1-S59, 2009-Perceived yet often misunderstood demands of a sport, overt benefits of anabolic drugs, and the inability to be offered any effective alternatives has fueled anabolic drug abuse despite any consequences. Motivational interactions with many situational demands including the desire for improved body image, sport performance, physical function, and body size influence and fuel such negative decisions. Positive countermeasures to deter the abuse of anabolic drugs are complex and yet unclear. Furthermore, anabolic drugs work and the optimized training and nutritional programs needed to cut into the magnitude of improvement mediated by drug abuse require more work, dedication, and preparation on the part of both athletes and coaches alike. Few shortcuts are available to the athlete who desires to train naturally. Historically, the NSCA has placed an emphasis on education to help athletes, coaches, and strength and conditioning professionals become more knowledgeable, highly skilled, and technically trained in their approach to exercise program design and implementation. Optimizing nutritional strategies are a vital interface to help cope with exercise and sport demands (). In addition, research-based supplements will also have to be acknowledged as a strategic set of tools (e.g., protein supplements before and after resistance exercise workout) that can be used in conjunction with optimized nutrition to allow more effective adaptation and recovery from exercise. Resistance exercise is the most effective anabolic form of exercise, and over the past 20 years, the research base for resistance exercise has just started to develop to a significant volume of work to help in the decision-making process in program design (). The interface with nutritional strategies has been less studied, yet may yield even greater benefits to the individual athlete in their attempt to train naturally. Nevertheless, these are the 2 domains that require the most attention when trying to optimize the physical adaptations to exercise training without drug use.Recent surveys indicate that the prevalence of androgen use among adolescents has decreased over the past 10-15 years (). The decrease in androgen use among these students may be attributed to several factors related to education and viable alternatives (i.e., sport supplements) to substitute for illegal drug use. Although success has been achieved in using peer pressure to educate high school athletes on behaviors designed to reduce the intent to use androgens (), it has not had the far-reaching effect desired. It would appear that using the people who have the greatest influence on adolescents (coaches and teachers) be the primary focus of the educational program. It becomes imperative that coaches provide realistic training goals for their athletes and understand the difference between normal physiological adaptation to training or that is pharmaceutically enhanced. Only through a stringent coaching certification program will academic institutions be ensured that coaches that they hire will have the minimal knowledge to provide support to their athletes in helping them make the correct choices regarding sport supplements and performance-enhancing drugs.The NSCA rejects the use of androgens and hGH or any performance-enhancing drugs on the basis of ethics, the ideals of fair play in competition, and concerns for the athlete's health. The NSCA has based this position stand on a critical analysis of the scientific literature evaluating the effects of androgens and human growth hormone on human physiology and performance. The use of anabolic drugs to enhance athletic performance has become a major concern for professional sport organizations, sport governing bodies, and the federal government. It is the belief of the NSCA that through education and research we can mitigate the abuse of androgens and hGH by athletes. Due to the diversity of testosterone-related drugs and molecules, the term androgens is believed to be a more appropriate term for anabolic steroids.

Exercise training before and after lung transplantation

The benefits of exercise training in individuals with chronic lung diseases such as chronic obstructive pulmonary disease, cystic fibrosis, and interstitial lung disease have been well documented. Although there is limited research available, it appears that exercise is safe and beneficial for people with severe end-stage chronic lung disease who are awaiting lung transplantation in addition to recipients of lung transplants. Evidence-based guidelines for exercise training in the pre- and post-lung transplantation phases have not yet been developed. However, by considering exercise guidelines for people with chronic lung disease and in older adults in light of the physiological changes that can occur either pre- or post-lung transplantation, a safe and appropriate exercise training program can be developed. Depending on the individual's exercise capacity and goals, the training program may include aerobic and resistance exercise, and flexibility and balance training. In the pre-transplant and acute post-transplant phases, the intensity of exercise is dictated primarily by symptom limitation and adequate rest, which is required between exercise bouts to allow for recovery. In the post-transplant phase, it is possible for lung transplant recipients to increase their exercise capacity and even participate in sports. Further research needs to be conducted to determine the optimal training guidelines and the long-term benefits of exercise, both in lung transplant candidates and recipients.

Airflow obstruction and exercise

The primary abnormality in chronic obstructive pulmonary disease (COPD) is chronic airway inflammation which results in airflow limitation. Disease progression is usually depicted as an accelerated decline in FEV(1) over time. However, COPD patients also manifest progressive static hyperinflation due to the combined effects of reduced lung elastic recoil and increased airway resistance. Superimposed on static hyperinflation are further increases in operational lung volumes (dynamic hyperinflation) brought on during exercise, exacerbations or tachypnea. An important consequence of exertional dyspnea is activity limitation. COPD patients have been shown to spend only a third of the day walking or standing compared with age-matched healthy individuals who spend more than half of their time in these activities. Furthermore, the degree of activity limitation measured by an accelerometer worsens with disease progression. COPD patients have been shown to have an accelerated loss of aerobic capacity (VO(2)max) and this correlates with mortality just as is seen with hypertension, diabetes and obesity. Thus physical inactivity is an important therapeutic target in COPD. Summarizing; airflow obstruction leads to progressive hyperinflation, activity limitation, physical deconditioning and other comorbidities that characterize the COPD phenotype. Targeting the airflow obstruction with long-acting bronchodilator therapy in conjunction with a supervised exercise prescription is currently the most effective therapeutic intervention in earlier COPD. Other important manifestations of skeletal muscle dysfunction include muscle atrophy and weakness. These specific problems are best addressed with resistance training with consideration of anabolic supplementation.

A review of the GOLD guidelines for the diagnosis and treatment of patients with COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of death in the USA, and represents a major health, social and economic burden. COPD is underdiagnosed and often misdiagnosed, which likely contributes to the continuing increases in the prevalence, morbidity and mortality associated with this disease. This is unfortunate because whereas COPD cannot be cured, it can be treated effectively, particularly during the earlier stages of the disease. Evidence-based guidelines, developed to assist in the prevention, diagnosis and management of COPD, are available to healthcare professionals interested in learning more about COPD. These guidelines are updated and revised on a regular basis to reflect recent advances in our understanding of the pathophysiology of and treatments available for COPD. Nevertheless, primary-care physicians have reported a lack of awareness of the fundamental concepts underpinning the optimal treatment and management of COPD presented in the guidelines. Thus, the objective of this article is to summarise key physiologic, diagnostic and management concepts provided in the most recent update of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which were published in November 2006.

The effect of strength training on functional fitness in older patients with chronic lung disease enrolled in pulmonary rehabilitation

The purpose of this study was to compare the effects of a strength training-enhanced program and a traditional pulmonary rehabilitation (PR) program on functional fitness (FF) in older patients with chronic obstructive pulmonary disease (COPD), using the Senior Fitness Test. Twenty patients were recruited from an outpatient PR program. After completing baseline measures, including muscular strength and the Senior Fitness Test, patients were randomly assigned to the strength training program (TR+ST, n = 10) or traditional PR program (TR, n = 10). Patients completed 16 exercise sessions that were conducted twice a week for 8-10 weeks, after which patients repeated outcome measurements. Independent t tests were conducted to determine whether groups differed between measures. Both the TR+ST and TR groups improved on all FF measures. Moderate effect sizes were found for two of the FF measures when the groups were compared. The addition of strength training to PR may have a favorable impact on FF in older patients with COPD.

Treinamento de força para pacientes com doença pulmonar obstrutiva crônica

Pacientes com doença pulmonar obstrutiva crônica apresentam comumente fraqueza muscular periférica associada à intolerância ao exercício. Embora efetivo, o exercício aeróbio apresenta pouco ou nenhum efeito na fraqueza e atrofia muscular, além de não ser tolerado pela maioria dos pacientes com DPOC. Nesse sentido, o treinamento de força é opção racional para aumentar a força muscular, além de já ter se mostrado mais tolerável que o exercício aeróbio. O aumento de força muscular periférica é o benefício mais consistente do treinamento de força e, quando este é associado ao exercício aeróbio, não resulta em melhora adicional da capacidade de exercício, da dispnéia e da qualidade de vida. Contudo, observa-se que o treinamento combinado é fisiologicamente mais completo e pode ser uma opção de condicionamento físico mais diversificado. O treinamento de moderada a alta intensidade resulta em maiores adaptações fisiológicas, entretanto o exercício de baixa intensidade é tolerável, simples, de fácil execução domiciliar, não requer equipamentos sofisticados e resulta em benefícios significativos. Este exercício é indicado, sobretudo, para os pacientes com DPOC mais avançada. Finalmente, há evidências recentes de que o treinamento de força para os músculos do tronco é alternativa válida para melhorar a capacidade funcional de exercício e a função pulmonar em pacientes com DPOC. A presente revisão de literatura sugere a incorporação do treinamento de força como estratégia de rotina nos programas de reabilitação pulmonar. Pesquisas futuras são necessárias para avaliar os efeitos do treinamento de força na saúde mental, no desempenho em atividades de vida diária, na saúde osteoarticular, no risco de quedas e na função pulmonar, entre outros.

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

BACKGROUND

Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

METHODS

The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.

RESULTS

The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.

CONCLUSIONS

There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Manifestações sistêmicas na doença pulmonar obstrutiva crônica

A doença pulmonar obstrutiva crônica é progressiva e está relacionada a uma resposta inflamatória anormal dos pulmões à inalação de partículas e/ou gases tóxicos, sobretudo a fumaça de cigarro. Embora acometa primariamente os pulmões, diversas manifestações extrapulmonares relacionadas a esta enfermidade têm sido descritas. O aumento do número de células inflamatórias, que resulta em produção anormal de citocinas pró-inflamatórias, e o desequilíbrio entre a formação de radicais livres e a capacidade antioxidante, resultando em sobrecarga oxidativa, provavelmente são mecanismos envolvidos na inflamação local e sistêmica. Além disso, a diminuição do condicionamento físico secundária às limitações ventilatórias pode estar envolvida no desenvolvimento de alterações musculares. A doença pulmonar obstrutiva crônica apresenta diversas manifestações sistêmicas que incluem a depleção nutricional, a disfunção dos músculos esqueléticos, que contribui para a intolerância ao exercício, e as manifestações relacionadas a co-morbidades comumente observadas nestes pacientes. Essas manifestações têm sido relacionadas à sobrevida e ao estado geral de saúde dos pacientes. Nesse sentido, esta revisão tem como objetivo discutir os achados da literatura relacionados às manifestações sistêmicas da doença pulmonar obstrutiva crônica, ressaltando o papel da inflação sistêmica, e algumas perspectivas de tratamento.

Peripheral muscle strength training in COPD: a systematic review

BACKGROUND

Skeletal muscle weakness, and the associated impact on exercise tolerance, provides a strong theoretical rationale for strength training intervention for people with COPD.

AIM

The purpose of this review was to examine systematically the current evidence for peripheral muscle strength training in people with COPD.

METHOD

Empirical trials and reviews relating to strength training in COPD were obtained by searching electronic databases and citation tracking, using the keywords of COPD with strength/resistance training and skeletal muscle. Two reviewers completed data extraction and quality assessment independently, using the PEDro (physiotherapy evidence database) scale and a checklist for review articles. Effect sizes and 95% confidence intervals were determined for empiric trials and metaanalysis used where appropriate.

RESULTS

The search strategy yielded 13 articles (9 empirical trials and 4 reviews). Strength training was found to have strong evidence for improving upper body and leg strength. However, no strong evidence for strength training was found for other outcome measures.

CONCLUSIONS

Further research is required to investigate the effects of strength training on functional activities, such as balance, upper limb function, self care, and participation in daily life.

Heavy resistance training increases muscle size, strength and physical function in elderly male COPD-patients—a pilot study

This study investigated the effects of heavy resistance training in elderly males with chronic obstructive pulmonary disease (COPD). 18 Home-dwelling male patients (age range: 65-80 years), with a mean forced expiratory volume in the first second (FEV1) of 46 +/- 3.4% of predicted value, were recruited. Baseline and post-training assessments included: Cross-sectional area (CSA) of quadriceps assessed by MRI, isometric and isokinetic knee extension strength, isometric trunk strength, leg extension power, normal and maximal gait-speed on a 30 m track, stair climbing time, number of chair stands in 30 s, lung function (FEV1) and self-reported health. Subjects were randomized to a resistance training group (RE, n = 9) or a control group conducting breathing exercises (CON, n = 9). RE performed heavy progressive resistance training twice a week for 12 weeks. 6 RE and 7 CON completed the study. In RE the following improved (P < 0.05): Quadriceps CSA: 4%, isometric knee extension strength: 14%, isokinetic knee extension strength at 60 degrees /s.: 18%, leg extension power: 19%, maximal gait speed: 14%, stair climbing time: 17%, isometric trunk flexion: 5% and self-reported health. In CON no changes were found. In conclusion, 12 weeks of heavy resistance training twice a week resulted in significant improvements in muscle size, knee extension strength, leg extension power, functional performance and self-reported health in elderly male COPD patients.

Recondicionamento muscular na DPOC: principais intervenções e novas tendências

Há algum tempo o condicionamento físico vem sendo parte obrigatória no tratamento de portadores de DPOC. Estes pacientes apresentam comumente intolerância ao exercício de intensidade variável e relacionada à disfunção muscular esquelética. Neste sentido, o exercício físico apresenta-se como ramo mais importante no processo de reabilitação pulmonar. O exercício aeróbio e o treino de força com pesos são fundamentais no incremento de capacidade física e qualidade de vida, principalmente naqueles indivíduos que apresentam as formas moderada ou grave da DPOC. Além disso, espera-se atualmente maior desenvolvimento nas pesquisas em relação à aplicação de estimulação elétrica neuromuscular (EENM) e ao uso criterioso de substâncias ergogênicas tais como esteróides anabolizantes e creatina oral. Tendo em vista as repercussões negativas da disfunção muscular e a importância da reabilitação pulmonar no tratamento da DPOC, esta revisão tem como objetivo reunir informações de estudos relevantes acerca das principais estratégias para o recondicionamento muscular esquelético nestes pacientes nos últimos 15 anos.

Exercise and aging

There is increasing evidence that the black box we have referred to as"biologic aging" is composed of genetic factors and many types of environmental exposures. Some of the most potentially modifiable elements of this syndrome are those attributable to disuse or insufficient exposure to certain kinds or intensities of physical stressors during the course of the life span. Beneficial adaptations to exercise once thought restricted to genetically endowed master athletes now are seen to occur just as predictably in frail elders with chronic disease, opening the door to vastly improved physical function and associated health benefits. Knowledge of the benefits of physical activity, however well substantiated, may be necessary, but it is not sufficient to change either physician-prescribing habits or the likelihood of adoption and long-term adherence to exercise on the part of patients. Ultimately, the penetration of an exercise prescription to optimize aging into the most inactive cohorts in the community,who have the most to gain from increases in levels of physical activity and fitness, will depend on a combination of clear evidence-based guidelines coupled with health professional training and behavioral programs tailored to age-specific barriers and motivational factors.

Exercise intervention in patients with chronic obstructive pulmonary disease (CE)

Chronic obstructive pulmonary disease (COPD) is characterized by worsening airflow obstruction. In its late stages, patients experience decreased physical function and increased incidents of pneumonia, pulmonary hypertension, cor pulmonale, and chronic respiratory failure. Patients who regularly participate in moderate exercise experience greater control of symptoms and increased functional capacity compared with those being treated by pharmacologic measures alone. Guidelines for a comprehensive exercise program are provided. The Seven Step Approach is discussed as a means of motivating older adults with COPD to incorporate physical exercise into their daily activity. Encouraging exercise in older adults with COPD will help these individuals reach and maintain their highest level of function and quality of life.