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

Principles of rehabilitation and reactivation

Skeletal muscle dysfunction and physical inactivity are two clinically important features of a wide range of acute and chronic respiratory conditions. Optimisation of both of these features is important in order to improve physical function, prevent clinical deterioration and maximise community participation. One of the most potent and evidence-based interventions to address these physical deficits is pulmonary rehabilitation (PR). Whilst the majority of PR research has been conducted in patients with chronic obstructive pulmonary disease, there is widespread recognition that PR can benefit many other respiratory patient groups. These include patients with interstitial lung diseases, asthma, pulmonary hypertension, pre-/post-lung surgery (e.g. lung cancer, transplantation) and cystic fibrosis to name a few. Exercise training must be appropriately prescribed by a skilled healthcare professional with comprehensive knowledge of the pathology and physiology of these conditions, as well as a sound understanding of the exercise physiology and core principles of exercise prescription, monitoring and progression. It has also become increasingly recognised that people with respiratory conditions, particularly those with chronic disease, are considerably less active than those of good health. PR should therefore aim to induce behavioural change to facilitate the adoption and maintenance of an active lifestyle. In addition, PR should pay attention to the psychological well-being of patients and self-management of their lung disease in all its aspects. To that end, multidisciplinary individualised programs should be offered. This review sets the scene of PR principles for a series of papers that will focus on specific diseases other than chronic obstructive pulmonary disease where rehabilitation may offer a clinically important aspect of care over and above conventional pharmacological treatment.

Four weeks' intensive rehabilitation generates significant health effects in COPD patients

Changes in health according to World Health Organization's International Classification of Functioning, Disability and Health (ICF) after four weeks of pulmonary rehabilitation (PR) were investigated. Gender differences in the response to PR, and the correlation between improvements in the two components of ICF (Body functions and Activities and Participation) were examined. Twenty-two men and 18 women with chronic obstructive pulmonary disease in Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II-IV attended in-patient, multidisciplinary PR consisting of endurance training four to five times/week at 70% of peak work rate (WRpeak), resistance training three to four times/week at 72% of 15 repetitions maximum, educational sessions and individual counselling. The results were compared to those of 20 Chronic Obstructive Pulmonary Disease (COPD) patients included after the same criteria and investigated while waiting for admission to PR. In the rehabilitation group, we found significant improvements in health related quality of life (HRQoL) (-7 units, St. George's Respiratory Questionnaire), arm (6%) and leg (15%) maximal voluntary contraction, peak oxygen uptake (6%), WRpeak (60%) and treadmill endurance time (93%). At iso-WR, ventilation and dyspnoea were significantly lower, but inspiratory capacity remained unchanged. Improvements in HRQoL correlated with increases in peak ventilation, but not in muscle strength or exercise capacity. Men improved their six-minute walking distance significantly in contrast to women. Clinically important improvements in HRQoL were found in two out of three of the men, and one out of three of the women. Four weeks of intensive PR generated significant health effects comparable to longer lasting programmes. Changes in exercise capacity and muscle strength were not related to improvements in HRQoL. The gender differences in the response to PR deserve attention in future studies.