Effect of three exercise programs on patients with chronic obstructive pulmonary disease

Effects of robot-assisted arm training on respiratory muscle strength, activities of daily living, and quality of life in patients with stroke: a single-blinded randomized controlled trial

BACKGROUND

Post-stroke clinical changes not only affect extremities and trunk muscles but also the respiratory muscles.

PURPOSE

To determine the effect of robot-assisted arm training with conventional rehabilitation (CombT) on respiratory muscle strength, activities of daily living (ADL), and quality of life in patients with stroke and to compare the results with conventional rehabilitation (CR).

METHODS

It was a two-arm, single-blinded, randomized controlled trial in which 66 patients were randomly allocated to either CombT or CR to receive 30 sessions (5/week) over 6 weeks. The respiratory muscle strength (maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP)), activities of daily life (ABILHAND questionnaire), and quality of life (Stroke Impact Scale (SIS)) were measured before and 6 weeks after training.

RESULTS

The CombT group showed significantly better MIP, MEP, and performance in ADLs after 6 weeks of training compared to the CR group (p < .01). The effect size was large for MIP (d = 0.9) and MEP (d = 0.9), whereas medium for performance in ADLs (d = 0.62). Also, the SIS-arm strength (p < .01), hand function (p = .04), ADLs (p = .02), and recovery (p = .04) were significantly better in CombT group with a medium (d = 0.6, d = 0.5, d = 0.5, and d = 0.5, respectively) effect size compared with CR group.

CONCLUSIONS

Both CombT and CR groups improved respiratory muscle strength, performance in ADLs, and quality of life in patients with stroke. However, CombT appears to offer more comprehensive benefits, highlighting its valuable role in respiratory and functional recovery after stroke.

Combined Exercise Training and Nutritional Interventions or Pharmacological Treatments to Improve Exercise Capacity and Body Composition in Chronic Obstructive Pulmonary Disease: A Narrative Review

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that is associated with significant morbidity, mortality, and healthcare costs. The burden of respiratory symptoms and airflow limitation can translate to reduced physical activity, in turn contributing to poor exercise capacity, muscle dysfunction, and body composition abnormalities. These extrapulmonary features of the disease are targeted during pulmonary rehabilitation, which provides patients with tailored therapies to improve the physical and emotional status. Patients with COPD can be divided into metabolic phenotypes, including cachectic, sarcopenic, normal weight, obese, and sarcopenic with hidden obesity. To date, there have been many studies performed investigating the individual effects of exercise training programs as well as nutritional and pharmacological treatments to improve exercise capacity and body composition in patients with COPD. However, little research is available investigating the combined effect of exercise training with nutritional or pharmacological treatments on these outcomes. Therefore, this review focuses on exploring the potential additional beneficial effects of combinations of exercise training and nutritional or pharmacological treatments to target exercise capacity and body composition in patients with COPD with different metabolic phenotypes.

Can Blood Biomarkers Be Used to Assess Oxidative Stress in COPD Patients After Pulmonary Rehabilitation

Purpose

To determine the level of oxidative stress in the body due to pulmonary rehabilitation (PR) with thiols and disulfide and to investigate their relationship with indirect markers such as creatine kinase (CK), creatine kinase - MB (CK-MB), and lactate dehydrogenase (LDH), which show cell destruction.

Patients and Methods

Patients with chronic obstructive pulmonary disease (COPD) are included in inpatient and outpatient care. They were evaluated before and after for PR, and an exercise program was prescribed. In addition, native thiol (NT), total thiol (TT), disulfide (DS), LDH, CK, and CK-MB values were tested.

Results

The mean age of 21 patients was 63±7.31 years. Eleven of them were outpatients and 10 of them were inpatients. Most of the patients were male (M/F=20/1, 95.2/4.8%). There was a significant difference in pulmonary function tests (PFT), St. George Respiratory Questionnaire (SGRQ), and 1 repetition maximum (1RM) before and after the treatment (p<0.001). There was a correlation between PFT and 1RM upper extremity. While there was no significant difference between thiols and disulfide, according to GOLD scores, there was a significant difference in patients with level 3-MMRC. No correlation was found between LDH, CK, CK-MB, and thiols, DS. ΔCK was found to be associated with ΔDS, and ΔCK-MB with ΔNT, and ΔTT.

Conclusion

PR contributes to the antioxidant process by improving respiration and reducing oxidative stress. The decrease in LDH, CK with PR, increase in CK-MB, and correlation of CK with thiols and DS gave a different interpretation. In this case, it should be considered that oxidative stress may also be increased in people with high CK values.

Efficacy of interventions to alter measures of fat-free mass in people with COPD: a systematic review and meta-analysis

Introduction

Low fat-free mass (FFM) is linked to poor health outcomes in COPD, including impaired exercise tolerance and premature death. The aim of this systematic review was to synthesise evidence on the effectiveness of interventions for increasing FFM in COPD.

Methods

Searches of electronic databases (MEDLINE, Cochrane Library, Embase, Web of Science, Scopus) and trial registers (ClinicalTrials.gov) were undertaken from inception to August 2022 for randomised studies of interventions assessing measures of FFM in COPD. The primary outcome was change in FFM (including derivatives). Secondary outcomes were adverse events, compliance and attrition.

Results

99 studies (n=5138 people with COPD) of 11 intervention components, used alone or in combination, were included. Exercise training increased mid-thigh cross-sectional area (k=3, standardised mean difference (SMD) 1.04, 95% CI 0.02-2.06; p=0.04), but not FFM (k=4, SMD 0.03, 95% CI -0.18-0.24; p=0.75). Nutritional supplementation significantly increased FFM index (k=11, SMD 0.31, 95% CI 0.13-0.50; p<0.001), but not FFM (k=19, SMD 0.16, 95% CI -0.06-0.39; p=0.16). Combined exercise training and nutritional supplementation increased measures related to FFM in 67% of studies. Anabolic steroids increased FFM (k=4, SMD 0.98, 95% CI 0.24-1.72; p=0.009). Neuromuscular electrical stimulation increased measures related to FFM in 50% of studies. No interventions were more at risk of serious adverse events, low compliance or attrition.

Discussion

Exercise training and nutritional supplementation were not effective in isolation to increase FFM, but were for localised muscle and index measures, respectively. Combined, exercise and nutritional supplementation shows promise as a strategy to increase FFM in COPD. Anabolic steroids are efficacious for increasing FFM in COPD.

Satisfaction and Adherence of COPD Patients to a Conventional Training Associated with Functional Exercises and to a Conventional Training Isolated: A Qualiquantitative Study

PURPOSE

To verify, through quali-quantitative analysis, the satisfaction and adherence of patients with Chronic Obstructive Pulmonary Disease (COPD) to the insertion of functional circuit training into conventional training.

PATIENTS AND METHODS

23 patients with COPD from a randomized clinical trial were invited to participate in a quali-quantitative analysis after the training finalization, divided into FTG (Functional Training Group) and CTG (Conventional Training Group). A total of 21 patients participated [(FTG: n=10; 65.80±7.31 years; FEV₁/FVC: 56.44±12.67%) and CTG (n=11; 70.36±7.02 years; FEV₁/FVC: 55.89±8.20)]. For the qualitative evaluation, focus groups were performed, using a previously developed script. Adherence was verified by the presence in the training sessions that were prescribed, and the quantitative analysis was performed using questionnaires with multiple-choice questions (evaluation of the aspects that can interfere in a training). The participants were asked to define a grade between zero and ten regarding the aspects of the training (satisfaction).

RESULTS

In both groups, there was similar adherence (p=0.965) and satisfaction (p=0.341). The qualitative analysis identified seven themes and 17 codes, representing factors related to satisfaction and negative aspects, as follows: factors associated with satisfaction: self-efficacy management, physical and psychosocial improvement, interpersonal relationships, and proposed exercises. Negative aspects: pains, comorbidities, beliefs, and personal demotivation. In the quantitative analysis, was verified that an increase in the symptoms, the distance between home and training center, and personal problems were not factors that interfered in the adherence of the participants (p<0.05).

CONCLUSION

Similar satisfaction and adherence of patients with COPD were observed in the FTG and CTG and patients from FTG reported higher fatigue.

Isolated Resistance Training Programs to Improve Peripheral Muscle Function in Outpatients with Chronic Obstructive Pulmonary Diseases: A Systematic Review

This systematic review aims to establish which isolated resistance training (RT) programs have been used in outpatients with chronic obstructive pulmonary disease (COPD) and their impact on all aspects of peripheral skeletal muscle function. Electronic databases were systematically searched up to June 2021. The eligibility criteria were: (1) randomized controlled trials investigating the effects of supervised and isolated RT programs in outpatients with COPD and (2) RT programs lasting 8-12 weeks, (3) including at least one outcome measure related to trainable muscle characteristics. Initially, 6576 studies were identified, whereas 15 trials met the inclusion criteria. All the included trials reported that isolated RT improved both upper and lower limbs' maximal strength. Muscle endurance and power also increased after RT but received less attention in the analysis. Furthermore, few studies assessed the effect of RT on muscle mass and cross-sectional area, reporting only limited improvement. Isolated RT programs carried out 2-3 days a week for 8-12 weeks improved skeletal muscle function in individuals with COPD. The RT program should be specifically focused to the trainable muscle characteristic to be improved. For this reason, we further encourage the introduction of a detailed assessment of muscle function and structure during the pulmonary rehabilitation practice.

Six-minute walk test protocol variations in low-resource settings - A scoping review

BACKGROUND

The 6-min walk test (6MWT) is a validated tool, of submaximal intensity, used to objectively measure functional exercise capacity. In 2002, the American Thoracic Society (ATS) developed guidelines on standardising the implementation of the 6MWT. Despite the relative ease of conducting the 6MWT as per these guidelines, adaptations are implemented.

OBJECTIVES

Identify (1) what 6MWT adaptations to the ATS guidelines have been described in low-resource settings (LRS), (2) the purpose of the adapted 6MWT and (3) the reported argumentation for making these adaptations in relation to the specific context.

METHODS

Five databases were searched from inception until February 2021. Studies that adapted and conducted the 6MWT in LRS were included. Data concerning the study source, participants, 6MWT: purpose, variations, outcome and rationale were extracted.

RESULTS

A total of 24 studies were included. The majority of studies (n = 18; 75%) were conducted in lower-middle income countries. The most common adaptation implemented was variation to course length. Eight studies provided a rationale for adapting the 6MWT. Space constraint was the most common reason for adaptation.

CONCLUSION

The most common reason (space constraints) for adapting the 6MWT in LRS was addressed through adaptations in course length and/or configuration. The results of this review suggest that the value of the ATS-guided 6MWT in LRS may need to be re-evaluated.

CLINICAL IMPLICATIONS

Using adapted forms of the 6MWT may lead to an underestimation of a patient's abilities, misinformed discharge and developing inappropriate exercise programmes. Additionally, diverting from ATS guidelines may affect the continuity of care.

The Effect of a Pulmonary Rehabilitation on Lung Function and Exercise Capacity in Patients with Burn: A Prospective Randomized Single-Blind Study

We performed pulmonary function (PF) tests and factors affecting PF evaluation in 120 patients with inhalation injury to evaluate the effects of pulmonary rehabilitation (PR) in burn patients with inhalation injury. Patients were randomized into pulmonary rehabilitation (PR) group and conventional rehabilitation (CON) group. PF tests, including forced vital capacity (FVC), 1-s forced expiratory volume FEV1), maximum voluntary ventilation (MVV), and respiratory muscles strength (maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP)), were measured by mouth pressure meter in the sitting position. Diffusing capacity for carbon monoxide (DLco) was determined by the single-breath carbon monoxide technique. Peak cough flow (PCF) was measured by a peak flow meter. Diaphragmatic mobility (DM) was evaluated on anteroposterior fluoroscopy. All evaluations were performed in all groups at baseline and after 12 weeks. There were no differences in evaluations between the PR group and CON group before the intervention. There were significant improvements in the PCF and MIP (%) changes, taken before and after rehabilitation in the PR group, compared with the changes in the CON group (p = 0.01, and p = 0.04). There were no significant changes in the other parameters in the PR group compared with the changes in the CON group (p > 0.05). There were significant differences in DLco (%), MIP, MIP (%), and DM between the PR group and the CON group (p = 0.02, p = 0.005, and p = 0.001) after 12 weeks of rehabilitation. There were no differences between the PR group and CON group after 12 weeks rehabilitation in the other parameters (p > 0.05). PR for patients with major burns and smoke inhalation induced improved PCF, MIP, MIP (%), DLco (%), and DM. These results show that PR should be a fundamental component of the treatment program for patients with burns.

[Pulmonary rehabilitation in the in-hospital and outpatient phases]

Pulmonary rehabilitation programmes aim to improve aerobic capacity and enhance quality of life in patients with chronic pulmonary disease, facilitating their participation and integration in different areas and activities of daily living, through the prescription and performance of physical exercise, as well as education on risk factors and healthy living. In multidisciplinary processes, various health professionals work together to support patients through the rehabilitation process, guiding lifestyle changes to improve their level of physical activity, nutritional factors, smoking cessation, diabetes management, medication adherence and weight loss, based on theories of behavioural change. The main objective of pulmonary rehabilitation programmes is to empower users in self-care and facilitate long-term management of chronic lung disease.

Exercise Training in Patients with Chronic Respiratory Diseases: Are Cardiovascular Comorbidities and Outcomes Taken into Account?-A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases (ILD) frequently suffer from cardiovascular comorbidities (CVC). Exercise training is a cornerstone intervention for the management of these conditions, however recommendations on tailoring programmes to patients suffering from respiratory diseases and CVC are scarce. This systematic review aimed to identify the eligibility criteria used to select patients with COPD, asthma or ILD and CVC to exercise programmes; assess the impact of exercise on cardiovascular outcomes; and identify how exercise programmes were tailored to CVC. PubMed, Scopus, Web of Science and Cochrane were searched. Three reviewers extracted the data and two reviewers independently assessed the quality of studies with the Quality Assessment Tool for Quantitative Studies. MetaXL 5.3 was used to calculate the individual and pooled effect sizes (ES). Most studies (58.9%) excluded patients with both stable and unstable CVC. In total, 26/42 studies reported cardiovascular outcomes. Resting heart rate was the most reported outcome measure (n = 13) and a small statistically significant effect (ES = -0.23) of exercise training on resting heart rate of patients with COPD was found. No specific adjustments to exercise prescription were described. Few studies have included patients with CVC. There was a lack of tailoring of exercise programmes and limited effects were found. Future studies should explore the effect of tailored exercise programmes on relevant outcome measures in respiratory patients with CVC.

The Impact of Upper Limb Training with Breathing Maneuver in Lung Function, Functional Capacity, Dyspnea Scale, and Quality of Life in Patient with Stable Chronic Obstructive of Lung Disease

BACKGROUND

Exercise tolerance is one of the main impacts of COPD. COPD patients often experience dyspnea and fatigue after doing daily activities using their limb parts, even in simple thing such as lifting or grooming. Nowadays, many pulmonologists concerned in pulmonary rehabilitation to modify some limb training with breathing manoeuvre to get positive impact in stable COPD patient.

AIM

The purpose of this study is to examine the impact of this modified upper limb training in lung function, functional capacity, dyspnea scale, and quality of life in patients with stable COPD.

METHOD

This was a quasi-experimental study held in 2017 on 22 stable COPD patients (based on GOLD 2018 criteria). Patients were given modified upper limb training with breathing manoeuvre that leads and monitored by a physiotherapist and physician in 10-20 minutes twice a week for 8 weeks. Before and after completed all sessions of training, we measured pulmonary functions test include FEV1 and FVC, functional capacity by 6 MWT, dyspnea scale by mMRC, and quality of life by CAT assessment. Statistical analysis was performed by Wilcoxon and paired t-test.

RESULTS

There was an improvement of lung function, both FEV1 (40.7 ± 13.8 to 47.3 ± 14.2; p-value 0.001) and FVC (50.7 ± 14.1 to 54.1 ± 14.7; p-value: 0.207) after training. There was a significant change of functional capacity in 6 MWT mean (277.3 ± 80.8 to 319.1 ± 78.3; p-value: 0.001). There was an improved quality of life after training, measured by decreasing in CAT score (23.9 ± 5.5 to 18.3 ± 5.2; p-value: 0.000). There was no significant change in the mMRC scale (p-value: 0.429).

CONCLUSION

There was an improvement of lung function, functional capacity, and quality of life in stable COPD after upper limb training with breathing manoeuvre in stable COPD patients.

Comparison of Effects of Endurance and Strength Training Programs in Patients with COPD

Comparisons between endurance and strength training in chronic obstructive pulmonary disease (COPD) patients have produced equivocal findings when examining physical function and health-related quality of life (HRQL). One reason for these differences may be due to individual patient responses to the different training modalities.

PURPOSE

To compare changes in physical function and HRQL in a group of COPD patients completing both an endurance and a strength training program.

METHODS

Eleven mildly diseased patients completed a three month endurance training program and, approximately 5 years later, completed a three month strength training program. Changes in 6 minute walk distance (6 MW), time to rise from a chair five times (CRT), and the total score and subscores from the SF-36 and Chronic Respiratory Disease Questionnaire (CRQ) were examined.

RESULTS

The forced expiratory volume as a percent of predicted remained relatively constant over the 5 years (61.1 ± 5.9 vs. 60.0 ± 10.3). Endurance and strength training increased 6 MW by 48.2 ± 11.2 (p = 0.008) and 39.8 ± 9.8 (p = 0.001) meters, respectively. Endurance and strength training decreased CRT by 4.8 ± 0.7 (p = 0.001) and 1.3 ± 1.2 (p = 0.056) seconds, respectively. Endurance training resulted in greater improvements in HRQL as compared to strength training.

CONCLUSION

These results show that walk distance improves as a result of participating in either an endurance or a strength training program. However, an endurance training program leads to greater improvements in both general and disease specific measures of HRQL.

Changes in lower limb muscle function and muscle mass following exercise-based interventions in patients with chronic obstructive pulmonary disease: A review of the English-language literature

Chronic obstructive pulmonary disease (COPD) patients often experience lower limb muscle dysfunction and wasting. Exercise-based training has potential to improve muscle function and mass, but literature on this topic is extensive and heterogeneous including numerous interventions and outcome measures. This review uses a detailed systematic approach to investigate the effect of this wide range of exercise-based interventions on muscle function and mass. PUBMED and PEDro databases were searched. In all, 70 studies (n = 2504 COPD patients) that implemented an exercise-based intervention and reported muscle strength, endurance, or mass in clinically stable COPD patients were critically appraised. Aerobic and/or resistance training, high-intensity interval training, electrical or magnetic muscle stimulation, whole-body vibration, and water-based training were investigated. Muscle strength increased in 78%, muscle endurance in 92%, and muscle mass in 88% of the cases where that specific outcome was measured. Despite large heterogeneity in exercise-based interventions and outcome measures used, most exercise-based trials showed improvements in muscle strength, endurance, and mass in COPD patients. Which intervention(s) is (are) best for which subgroup of patients remains currently unknown. Furthermore, this literature review identifies gaps in the current knowledge and generates recommendations for future research to enhance our knowledge on exercise-based interventions in COPD patients.

Effect of "add-on" interventions on exercise training in individuals with COPD: a systematic review

The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Electronic databases were searched, identifying trials comparing exercise training with exercise training plus "add-on" therapy. Outcomes included peak oxygen uptake (V'_O2peak), work rate and incremental/endurance cycle and field walking tests. Individual trial effects on exercise capacity were extracted and collated into eight subgroups and pooled for meta-analysis. Sensitivity analyses were conducted to explore the stability of effect estimates across studies employing patient-centred designs and those deemed to be of "high" quality (PEDro score >5 out of 10). 74 studies (2506 subjects) met review inclusion criteria. Interventions spanned a broad scope of clinical practice and were most commonly evaluated via the 6-min walking distance and V'_O2peak. Meta-analysis revealed few clinically relevant and statistically significant benefits of "add-on" therapies on exercise performance compared with exercise training. Benefits favouring "add-on" therapies were observed across six different interventions (additional exercise training, noninvasive ventilation, bronchodilator therapy, growth hormone, vitamin D and nutritional supplementation). The sensitivity analyses included considerably fewer studies, but revealed minimal differences to the primary analysis. The lack of systematic benefits of "add-on" interventions is a probable reflection of methodological limitations, such as "one size fits all" eligibility criteria, that are inherent in many of the included studies of "add-on" therapies. Future clarification regarding the exact value of such therapies may only arise from adequately powered, multicentre clinical trials of tailored interventions for carefully selected COPD patient subgroups defined according to distinct clinical phenotypes.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A combination of resistance and endurance training increases leg muscle strength in COPD: An evidence-based recommendation based on systematic review with meta-analyses

Resistance training (RT) is thought to be effective in preventing muscle depletion, whereas endurance training (ET) is known to improve exercise capacity and health-related quality of life (HRQoL) in chronic obstructive pulmonary disease (COPD). Our objectives were to assess the efficiency of combining RT with ET compared with ET alone. We identified eligible studies through a systematic multi-database search. One author checked titles and abstracts for relevance using broad inclusion criteria, whilst two independent authors checked the full-text copies for eligibility. Two authors independently extracted data, and we assessed the risk of bias and quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation guidelines. We included 11 randomized controlled trials (331 participants) and 2 previous systematic reviews. The meta-analyses showed equal improvements in HRQoL, walking distance and exercise capacity. However, we found moderate quality evidence of a significant increase in leg muscle strength favouring a combination of RT and ET (standardized mean difference of 0.69 (95% confidence interval: 0.39-0.98). In conclusion, we found significantly increased leg muscle strength favouring a combination of RT with ET compared with ET alone. Therefore, we recommend that RT should be incorporated in rehabilitation of COPD together with ET.

Analysis of autonomic modulation after an acute session of resistance exercise at different intensities in chronic obstructive pulmonary disease patients

Purpose

Physical exercises are employed as part of the treatment of patients with chronic obstructive pulmonary disease (COPD); however information regarding cardiac autonomic modulation after an acute session of resistance exercise (RE) is unknown. The aim of this study was to evaluate the cardiac autonomic modulation, via heart rate variability after an acute session of RE applied at different intensities in COPD patients.

Patients and methods

Twelve COPD patients underwent an acute session of RE with an intensity of 60% and another of 90% of the one repetition maximum test. For analysis of autonomic modulation, heart rate was recorded beat-by-beat for 20 minutes at rest and after the training session. Heart rate variability indexes were obtained in the time and frequency domains for the assessment of autonomic modulation.

Results

Regardless of exercise intensity, RE acute sessions influenced the autonomic modulation when the recovery period was compared with the baseline. An increase in standard deviation of normal to normal RR intervals was observed throughout recovery time after the RE, as compared to baseline in both protocols: 60% and 90% of the one repetition maximum test. The spectral component of low frequency index (ms) was higher throughout recovery when compared to baseline in both protocols. The same was also observed in the spectral component of high frequency index (ms) for the protocols of 60% and 90%.

Conclusion

RE sessions impact on the autonomic modulation of COPD patients by promoting differences in the recovery period compared to baseline, regardless of the intensity of the exercise performed.

Functional outcomes in patients with chronic obstructive pulmonary disease: a multivariate analysis

Background

Multiple factors can influence the severity of chronic obstructive pulmonary disease (COPD) and the functioning of patients with COPD, such as personal characteristics and systemic manifestations.

Objective

To evaluate the different factors that can influence the activity and psychosocial impact domains of the Saint George's Respiratory Questionnaire (SGRQ) in COPD patients.

Method

Participants, recruited in a university-based hospital, responded to the SGRQ, and in addition, personal, anthropometric, and clinical data were collected. The study was approved by the Institutional Ethics Committee. Data were analyzed using multiple linear regression models, with the SGRQ activity and psychosocial impact scores as outcome variables, and 10 explanatory variables (age, gender, forced expiratory volume in the first second - FEV₁, smoking load, body mass index, oxygen therapy, associated diseases, regular physical activity, participation in a formal rehabilitation program, and SGRQ symptoms score) were considered.

Results

The best regression model for predicting the SGRQ activity score (r²=0.477) included gender, FEV₁, and SGRQ symptoms. In contrast, the predictive model with the highest proportion of explained variance in psychosocial impact score (r²=0.426) included the variables gender, oxygen therapy, and SGRQ symptoms.

Conclusions

The results indicate that the outcomes, while based on functioning parameters in COPD patients, could be partly explained by the personal and clinical factors analyzed, especially by the symptoms assessed by the SGRQ. Thus, it appears that the health conditions of these patients cannot be described by isolated variables, including pulmonary function parameters.

Reporting of exercise attendance rates for people with chronic obstructive pulmonary disease: a systematic review

While recommendations for the duration, frequency, mode and intensity of exercise programmes for people with chronic obstructive pulmonary disease (COPD) are specified in consensus statements, criteria for exercise session attendance are less clear. The review questions were: (i) how commonly are a priori criteria and attendance rates reported for people with COPD participating in exercise programmes and (ii) what is the strength of association between attendance and improvements in functional exercise capacity. Database searches identified primary studies of people with COPD participating in exercise or pulmonary rehabilitation programmes of at least 2 weeks duration. Primary outcomes were a priori criteria for attendance, reports of attendance at supervised exercise sessions and mean improvements in functional exercise assessments. Data extraction processes were confirmed prospectively (>80% agreement). Variants of exercise attendance data were described. Linear associations between attendance and improvements in exercise outcomes were explored (Pearson r, P < 0.05). Of the 234 included studies, 86 (37%) reported attendance and 29 (12%) provided a priori criteria for attendance. In the small sample of studies which reported attendance and functional exercise data before and after the intervention, there was little to no relationship between improvements in functional exercise capacity and training volume (prescribed r = -0.03, P = 0.88; attended r = -0.24, P = 0.18). Reporting of exercise programme attendance rates is low and of variable quality for people with COPD. Consistent and explicit reporting of exercise attendance in people with COPD will enable calculation of dose-response relationships and determine the value of a priori exercise attendance criteria.

Effects of resistance training on respiratory function in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

PURPOSE

Over the last decade, the potential use of resistance training (RT) for patients with chronic obstructive pulmonary disease (COPD) has gained increasing attention. Many COPD patients experience muscle dysfunction and reduced muscle mass, primarily as a result of chronic immobilization. These symptoms have been associated with reduced exercise tolerance and complaints of fatigue and dyspnea (even after minimal exertion). This paper presents findings from a systematic review that sought to: (1) present a meta-analysis of randomized controlled trials (RCT) investigating the effects of RT on respiratory function measures in patients with COPD and (2) investigate the existence of a dose-response relationship between intensity, duration and frequency of RT and assessed outcomes.

METHODS

A systematic literature search of MEDLINE electronic database (January 1980 to December 2009) produced a body of research on the effects of RT with a control group in patients with COPD. Data analysis involved a random effects meta-analysis, in order to determine weighted mean differences with 95 confidence intervals (95% CI) for each endpoint. All data were analyzed with the software package Review Manager V 4.2.10 (of the Cochrane Collaboration); 14 RCTs were included in the meta-analysis.

RESULTS

Findings demonstrated that RT did not substantially increase forced expiratory volume in 1 s. In addition, the weighted mean difference was 2.71% of predicted (95% CI, -1.86 to 7.27; p = 0.25) or by absolute 0.08 L (95% CI, -0.03 to 0.19; p = 0.14). It appeared that maximum minute ventilation increased by 3.77 L/min (95% CI, -0.51 to 8.04; p = 0.08).

CONCLUSIONS

Based on findings from the meta-analysis, RT produces a clinically and statistically significant effect on respiratory function (such as forced vital capacity) and is therefore recommended in the management of COPD.

Evaluation of articles on pulmonology published in Brazilian journals other than the Brazilian Journal of Pulmonology

In Brazil, research on pulmonology has become increasingly more visible in recent years. In addition to the Brazilian Journal of Pulmonology, other journals have contributed to that by publishing relevant articles in this area. The objective of this article was to briefly report the most relevant studies on pulmonology that were published in other important Brazilian journals between 2009 and 2010. Altogether, there were 56 articles related to the various subareas that compose the field of respiratory diseases.

Strength training increases maximum working capacity in patients with COPD--randomized clinical trial comparing three training modalities

BACKGROUND AND OBJECTIVE

Skeletal muscle dysfunction contributes to exercise limitation in patients with chronic obstructive pulmonary disease (COPD). Strength training increases muscle strength and muscle mass, but there is an ongoing debate on the additional effect concerning the exercise capacity. The purpose of this study was to compare the effects of three different exercise modalities in patients with COPD including endurance training (ET), progressive strength training (ST) and the combination of strength training and endurance training (CT).

DESIGN

A prospective randomized trial.

METHODS

Thirty-six patients with COPD were randomly allocated either to ET, ST, or CT. Muscle strength, cardiopulmonary exercise testing, lung function testing and quality of life were assessed before and after a 12-week training period.

RESULTS

Exercise capacity (Wmax) increased significantly in all three training groups with increase of peak oxygen uptake (VO2peak) in all three groups, reaching statistical significance in the ET group and the CT group. Muscle strength (leg press, bench press, bench pull) improved in all three training groups, with a higher improvement in the ST (+39.3%, +20.9%, +20.3%) and the CT group (+43.3%, +18.1%, +21.6%) compared to the ET group (+20.4%, +6.4%, +12.1%).

CONCLUSIONS

Progressive strength training alone increases not only muscle strength and quality of life, but also exercise capacity in patients with COPD, which may have implications in prescription of training modality. CLINICALTRIALS.GOV IDENTIFIER: NCT01091623.

Reliability in one-repetition maximum performance in people with Parkinson's disease

Strength training is an effective modality to improve muscular strength and functional performance in people with Parkinson's disease (PWP). One-repetition maximum (1-RM) is the gold standard assessment of strength; however, PWP suffer from day-to-day variations in symptom severity and performance characteristics, potentially adversely affecting the reliability of 1-RM performance. Herein, we assessed the reliability of 1-RM in PWP. Forty-six participants completed two sessions of 1-RM testing of knee extension, knee flexion, chest press, and biceps curl at least 72 hours apart. Significantly differences between testing sessions were identified for knee extension (P < 0.001), knee flexion (P = 0.042), and biceps curl (P = 0.001); however, high reliability (ICC > 0.90) was also identified between sessions. Interestingly, almost third of subjects failed to perform better on the second testing session. These findings suggest that 1-RM testing can be safely performed in PWP and that disease-related daily variability may influence 1-RM performance.

Factors associated with the minimal clinically important difference for health-related quality of life after physical conditioning in patients with COPD

OBJECTIVE

To identify factors associated with the minimal clinically important difference (MCID) for health-related quality of life (HRQoL) after physical conditioning in patients with COPD.

METHODS

Thirty-five patients were submitted to a 12-week program of physical conditioning (strength training plus low-intensity aerobic exercise). Body composition, incremental treadmill test results, endurance treadmill test results, six-minute walk test results, peripheral muscle strength, MIP, baseline dyspnea index (BDI) and Saint George's Respiratory Questionnaire (SGRQ) scores were assessed at baseline and after the program, thus allowing the variations (Delta) to be calculated. The MCID for HRQoL was defined as a reduction of > 4% in the SGRQ total score. Subjects who responded to the program, achieving the MCID for HRQoL, were allocated to the responders (R) group (n = 24), and the remainder were allocated to the non-responders (NR) group (n = 11).

RESULTS

The values obtained for the following variables were significantly higher in group R than in group NR (p < 0.05): FEV1 (1.48 + or - 0.54 L vs. 1.04 + or - 0.34 L); VEF1/FVC (47.9 + or - 11.7% vs. 35.5 + or - 10.7%); PaO2 (74.1 + or - 9.7 mmHg vs. 65.0 + or - 8.9 mmHg); and DeltaBDI, expressed as median and interquartile range (2.0 [0.0-3.5] vs. 0.0 [0.0-1.0]). The DeltaBDI correlated significantly with the DeltaSGRQ symptoms domain score, activity domain score and total score (r = 0.44, 0.60 and 0.62, respectively, p < 0.01 for all). After logistic regression, only DeltaBDI remained as a predictor of MCID for HRQoL.

CONCLUSIONS

Achieving the MCID for HRQoL after physical conditioning is associated with dyspnea reduction in COPD patients. Therefore, there is a need to develop treatment strategies designed to interrupt the dyspnea-inactivity-dyspnea cycle in such patients.